Metastatic peritoneal surface disease from gastrointestinal, gynecologic and rarer primary peritoneal cancers is a challenging clinical scenario. These patients are frequently afflicted by symptomatic abdominal swelling, malnourishment, and various degrees of obstructive bowel symptoms. Though less common than lung or prostate cancer, there are tens of thousands of patients facing this difficult situation every year.
Traditional systemic chemotherapy is not routinely effective for patients with peritoneal disease because it does not optimally reach the target tissue. The tumors are often low grade and mucinous, known to be relatively refractory to chemotherapy, and patients are often so debilitated that chemotherapy is very poorly tolerated.
Though challenged, these patients are not without hope. At specialized centers, Hyperthermic Intraperitoneal Chemotherapy is a technique that uniquely addresses peritoneal surface disease using the synergistic potential of hyperthermia and chemotherapy to eradicate tumors. Developed at the National Institutes of Health 30 years ago, HIPEC is a frequently used adjunct in this patient population.
HIPEC is preceded by aggressive cytoreduction, or removal of all visible tumor. Then the heated chemotherapy is directly applied in the operating room for 90 minutes using specialized circuitry and a perfusionist to treat the microscopic disease that remains following surgical resection. Because these two key components of surgical care for patients with metastatic peritoneal disease are often extensive and require specific technical expertise, HIPEC is best performed at high-volume centers.
The ideal patient
Though a significant number of patients with peritoneal disease can have their lives extended, or cured, with cytoreduction and HIPEC, not all patients are good candidates. Patients with appendiceal, colorectal, ovarian, and peritoneal mesothelioma cancers are all potential candidates for HIPEC. However, patients with extensive, high-grade cancers typically do not benefit from cytoreduction and HIPEC, and the significant post-operative recovery in this population can be a detriment to quality of life. Furthermore, HIPEC is not appropriate for peritoneal disease from pancreas cancer or gastric cancer.
Determining which patients should proceed to the operating room and those who are poorly served by these techniques is often complex, requiring significant patient and provider input, discussion, and shared-decision making. All patients with peritoneal spread of their cancer should be evaluated by a multidisciplinary team. Not all patients will ultimately undergo cytoreduction and HIPEC, but for the substantial proportion of patients who will benefit from aggressive surgical resection and HIPEC, these techniques may be the only hope for long-term survival.
Daniel Abbott, MD, is a surgical oncologist who specializes in liver, pancreas and peritoneal surface malignancies. He is the director of Cytoreductive and Hyperthermic Intraperitoneal Chemotherapy Surgery at the University of Wisconsin, working as part of a multidisciplinary team to optimize the outcomes of patients with these challenging diseases.