Hyperthermic intraperitoneal chemotherapy

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Intraperitoneal hyperthermic chemoperfusion (HIPEC or IPHC) is a type of hyperthermia therapy used in combination with surgery in the treatment of advanced stomach cancer. In this procedure, warm anti-cancer drugs are infused and circulated in the peritoneal cavity for a short time. Chemotherapy agents that are generally infused during IPHC are mitomycin-C and cisplatin.

Video Hyperthermic intraperitoneal chemotherapy

History

In 1934, Joe Vincent Meigs in New York originally described the operation of tumor debulking (cytoreductive surgery) for ovarian cancer under the premise of reducing macroscopic disease. In the 60s and 70s this aggressive cytoreductive approach began to be accepted. During this time, Dr. Kent Griffith at the National Cancer Institute also reported indicators of survival prognosis in patients with stage II and III ovarian cancer, noting that the residual tumor mass size (& lt; 1.6 cm) after sitoreductive surgery was significantly associated with prolonging survival. During this research began to show hyperthermia and intraperitoneal chemotherapy is effective in killing cancer cells. Spratt et al. in the 1980s, at the University of Louisville in Kentucky incorporated these concepts into a thermal transfusion infiltration system (TIFS) for the delivery of chemotherapy heated to the peritoneal spaces of canine teeth. The first human being was subjected to TIFS by administering hyperthermic chemotherapy to advanced local abdominal malignancy in 1979. Further studies in the 1980s gave chemotherapy agents at concentrations up to 30 times greater than those safely administered via route IV. In the mid to late 1980s, Sugarbaker led the Washington Cancer Institute further investigation into therapy for gastrointestinal malignancies with peritoneal spread and able to report survival benefits. It became clear early on that the completeness of cytoreduction was associated with survival benefits. In 1995, Sugarbaker made a gradual approach to cytoreduction, in an attempt to standardize and optimize this process.

The HIPEC technique is also further enhanced by suggesting some modalities of labor. The "Coliseum" technique as well as a similar approach described by Dr. Paul Sugarbaker in 1999 is an open stomach technique in which heated chemotherapy is poured in. The benefits of this open approach include direct access by the surgeon to the cavity during the administration of a hyperthermic agent to manipulate fluids and intestines to achieve rapid and homogeneous temperature and distribution of drugs in the stomach. In addition, care can be taken to ensure that all peritoneal surfaces are uniformly exposed throughout the duration of therapy and avoid dangerous temperatures or excessive exposure to normal tissues. For comparison, a closed technique involves closing the abdominal wall before chemotherapy infusion reduces the problem of heat loss from the peritoneal surface. In an effort to combine the potential advantages of these two techniques, Sugarbaker used a semi-open method by developing a new containment instrument (Thompson retraction) described in 2005 to support water-resistant from the edges of the abdominal skin. Recently, a laparoscopic approach for CRS with HIPEC in highly selected patients with less disease burden has been described.

Further progress is made in 2016, when Lotti M. et al. describes a new technique, the HIPEC-Enhanced Laparoscopic (LE-HIPEC) technique, in which hyperthermic chemotherapy is delivered after closure of stomach ulcers, and a laparoscopic approach is used to stir the entrails during perfusion. Lotti M questioned the assertion that the Coliseum technique could achieve a homogeneous heat distribution. The objective of LE-HIPEC is to achieve better heat delivery and preservation (as in closed techniques) and better perfusion fluid circulation (as in open techniques). Compared with the standard closed abdominal technique, the LE-HIPEC technique allows the surgeon to open the abdominal compartment to allow the entry of heated perfusion fluid. Additionally, it allows the identification and subdivision of early intra-abdominal adhesions that may inhibit the circulation of perfusion fluid during standard closed-abdominal perfusion. In further research, Lotti M et al. showed that after CRS intra-abdominal adhesion occurred in 70% of patients, immediately after wound closure.

Maps Hyperthermic intraperitoneal chemotherapy

HIPEC usage

IPHC is commonly used after surgical removal of as many cancers as possible (debulking), which may include removal of all areas of the peritoneum involved. This procedure can be 8-10 hours and carries a significant degree of complications. IPHC is used as a viable solution for certain advanced stage tumors in the stomach that have spread many small tumors throughout the abdomen, when surgery is impossible or effective. It can also be applied, during surgery, directly in the area, for those with advanced stomach cancer but still considered surgery, as an alternative to traditional surgery and chemotherapy alone.

The most commonly treated diseases with this method are appendectomy, colorectal cancer, ovarian cancer, desmoplastic round cell tumor, gastric cancer, muscular adenocarcinoma (MAC) appendix, mesothelioma, low-grade sarcoma.

Ovarian Cancer

Among patients with stage III epithelial ovarian cancer, the addition of HIPEC to cytoreductive surgery interval resulted in longer recurrence-free survival and overall survival rather than surgery alone and did not result in higher levels of adverse events.

Chemotherapy agents

Various chemotherapy is used and there is no clear consensus about what drugs to use. Mitomycin C and Oxaliplatin are the most common agents used for colorectal cancer, while Cisplatin is used in ovarian cancer.

• Mitomycin C
  • 30 mg in 3L for 60 minutes 10 mg for 40 minutes
• Oxaliplatin
  • Given bidirectional with intravenous 5-FU and oxalplatin in the peritoneum
    • 460Ã, mg/m2 for 30 minutes at 42Ã, Â ° -43Ã, Â ° C
    • I.V. 5-FU 400Ã, mg/m2 & amp; leucovorin 20Ã, mg/m2
• Cisplatin
• Irinotecan

src: www.ijaweb.org

Procedures

The procedure is divided into three stages:

1. Exploration : Here the surgeon will open the abdomen to evaluate the peritoneal cancer.
2. Debulking : In debulking, or cytoreduction, the procedure phase, the surgeon will remove visible tumor implants. However, even when all visible tumors are removed it is possible for microscopic cancer cells to remain. The last stage of the procedure is intended to remove the cells.
3. Chemoperfusion : Here the abdominal cavity is rinsed with a heated chemotherapy solution. Unlike systemic chemotherapy delivered in the bloodstream, throughout the body, chemotherapy in the HIPEC procedure is largely isolated in the peritoneal cavity. Therefore, higher chemotherapy concentrations can be utilized, while the toxicity and side effects associated with systemic chemotherapy are minimized.

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Controversy

While potentially curative, CRS plus HIPEC is associated with substantial perioperative morbidity and mortality and short-term decline in quality of life. Skeptical of this procedure argues that there is no multicenter 3 random phase trial that compares CRS HIPEC with complete cytoreduction followed by systemic therapy. Therefore, this therapy has not met the scientific standards to be considered standard of care. However, CRS supporters HIPEC contend that to date, no systemic therapy has provided long-term survival for peritoneal metastasis. Peritoneal metastases, based on primary tumors and extent of disease, have an overall overall survival of less than 36 months on systemic therapy alone. Treatment of peritoneal carcinomatosis of colorectal origin with cytoreductive surgery (CRS) plus intraperitoneal hyperthermic chemotherapy (HIPEC) has a recurrence or 5 year healing rate of at least 16%.

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References

src: www.westcancercenter.org

External links

• HIPEC, Patient's Guide

Source of the article : Wikipedia