The Christ Hospital Health Network is proud to welcome Rod Flynn, MD.
Dr. Flynn is a surgical oncologist and brings extensive experience and a new treatment focus to The Christ Hospital Health Network-Hyperthermic Intraperitoneal Chemotherapy (HIPEC), a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.
In this segment, we meet Dr. Flynn as he explains the HIPEC treatment and why it is so beneficial for certain cancer patients.
Introduction To Dr. Rod Flynn and HIPEC Treatments
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Learn more about Dr. Rod Flynn
Rod Flynn, MD
Dr. Rod Flynn is a Surgical Oncologist. He received his medical degree from University of Maryland School of Medicine in Baltimore and completed a surgical internship at Allegheny University Hospital in Philadelphia. He then completed a residency in general surgery at The Graduate Hospital in Philadelphia, followed by a fellowship in surgical oncology at the University of Pittsburgh Medical Center in Pittsburgh.Learn more about Dr. Rod Flynn
Transcription:
Introduction To Dr. Rod Flynn and HIPEC Treatments
Melanie Cole (Host): The Christ Hospital Network is proud to welcome Dr. Rod Flynn. Dr. Flynn is a Surgical Oncologist and brings extensive experience and a new treatment focus to the Christ Hospital Health Network. We’re going to be discussing HIPEC today, or hyperthermic intraperitoneal chemotherapy. Welcome to the show, Dr. Flynn. Let’s start by telling us a little bit about yourself and your philosophy of care.
Dr. Rod Flynn (Guest): Thank you very much for having me here today. My name is Rod Flynn and I’ve been in practice for about 14 years and for the last 9 of those years I’ve been focusing specifically on cancer. I received my Fellowship in Surgical Oncology in 2004 at the University of Pittsburgh and that is where I became enamored with the concept of Cytoreductive surgery and HIPEC, the reason being because this is a disease process that has been traditionally known as the “open and close” where the patient has some form of GI malignancy and they are taken to the operating room for a resection of their primary tumor and the patient gets opened up and the patient is found to have an Inordinate amount of cancer there and they are closed back up and they are told that nothing can be done other than chemotherapy and then they are given just a globally poor prognosis and so with this technique of cytoreductive surgery and HIPEC we are able to provide patients, on the contrary instead of being given essentially a death sentence, we’ve been able to give them hope that they would not have imagined that they would have had prior to the advent of this technique.
Melanie: So what are the types of cancer that you are looking at that HIPEC could be used for?
Dr. Flynn: Well it was used in the 1980’s for cancer of the appendix. There are 2 major categories. One of them is what we call pseudomyxoma peritonii which is a very bland type of mucinous debris that usually emanates from an appendix that has ruptured and it disseminates this mucinous or jelly like substance within the abdominal cavity and a lot of people would call that “Jelly belly” and so in the 1980’s the technique of debulking or what we now call cytoreduction which means reduction of cells or destruction or elimination of cells so I use the term cytoreduction synonymously with debulking.
So back in the 80’s these appendiceal tumors were treated with cytoreduction surgery and intraperitoneal chemotherapy and what they were finding was that patients could live literally decades without a significant recurrence of their disease, so that has been kind of the model that has been used since that time and it has been extrapolated to many other types of malignancies including, colon, stomach cancer and also this rare disease called diffuse malignant intraperitoneal mesothelioma. You hear a lot of that mesothelioma hype when it comes to lung cancer and the exposure to asbestos, but it turns out that the same kind of membrane that lines the lungs also lines the abdominal or peritoneal cavity, so you can see mesothelioma of the abdomen and actually HIPEC works quite well with that particular disease process as well. And also a bit more controversial is use in ovarian cancer, because what you find in ovarian cancer is that about 75% patients present with a disseminated form of this disease, which it is almost as if the tumor exploded in the abdomen and traditionally that has been treated with debulking and intravenous chemotherapy but again, we believe in the
In the HIPEC world, that HIPEC should also be considered in these patients, at least for their recurrences, after they have been treated with debulking and intravenous chemotherapy.
Melanie: So these are cancers that have spread to the lining surfaces of the abdominal cavity from other types of abdominal cancers but have not yet spread outside that peritoneal cavity?
Dr. Flynn: Correct.
Melanie: So explain to the listeners a little bit about what HIPEC actually is and how this heat, this type of chemotherapy works in conjunction with the surgery and cytoreduction surgery you were just discussing.
Dr. Flynn: Absolutely, so again, real quickly, the mechanism of what we see is first of all the diagnosis of what we call “Carcinomatosis”, or peritoneal metastases, and what you alluded to, what basically happens is, just imagine an intra-abdominal organ like say the stomach. What happens is that these cancers grow on the inner lining of the stomach or these other intra-abdominal organs, and what happens is in a lot of cases they will grow radially from the inside and kind of push their way to the outer surface of that organ and then from there it’s as if the cancer just explodes and it drops these implants throughout the abdominal or peritoneal cavity.
For the lack of a better metaphor I always refer to that peritoneal lining is like a trash bag that lines a trash can, and so imagine a tumor exploding if you will, and seeding all over that lining, and so that’s kind of the mechanism of what happens.
And so, in our technique, what we do, we don’t just open and close those patients. Often times we get those patients on referral, after they have been opened and closed, and by the way, a lot of people say that once the air hits it, it goes haywire and that’s really an old myth and is not how these cancers work.
Anyway at that point we would see the patient and do our own assessment to make sure they are a candidate, and by the way I will talk a little bit about that later, and if the still fit the description, we take them to the operation room with the express intention of removing all the visible disease, and that means not just the primary, so if it is a stomach cancer, we remove the part of the stomach that is involved, but then we explore the entire abdominal cavity, and any area that is peppered with these nodules we will remove. If a piece of organ has a confluence of these nodules, then we resect a piece of that organ. For example, the spleen is often just lined with these cells and we have to remove those. Sometimes the small intestine and what we call the greater omentum, which is this fatty apron that drapes the abdomen, and other areas, so our goal is to remove all visible tumor.
The other thing I would mention is that a lot of times we get these patients after they have already had multiple operations so we must begin when we get into the abdomen by lysing or dividing all the scar tissue to expose literally every surface of the abdominal cavity. That’s important, because later, when we distribute the chemotherapy, we want it to hit every nook and cranny.
So, anyway, we go in there and we remove all the visible cancer that’s there, and this can take anywhere from 5 hours to – my longest has been 17 and a half hours and painstakingly go through every nook and cranny of the abdominal cavity and try to remove all the visible tumor, and once we’ve done that, then we apply this heated chemotherapy. What we do is almost like a heart bypass circuit, where we hook them up to this machine and we bring a tubing that goes from the patient to the machine, and then there is a second set of tubing that goes from the machine back to the patient, so we circulate a fluid – usually about 3 liters to 3 ½ liters of fluid – we do this to heat their body up to a certain temperature between 41 and 41 ½ degrees centigrade, and then, once we’ve got their body to that steady state temperature then we apply the chemotherapy. And then what we do is close just the skin, leave those catheters in there and we do what’s called a “shake and bake”, so we just manually with our hands jostle the abdomen a little bit to get all that chemotherapy distributed. This process alone takes about 90 minutes, some people do 100 minutes, in our institution we’ve done it traditionally for 90 minutes, then we undo the skin sutures, drain all the chemotherapy out, and then, if we’ve resected a piece of, say, intestines, like a piece of pipe, say we had a bad pipe, we take a piece out, and ultimately we’re going to splice the pipe back together, well we leave the piece out when we’re doing the chemotherapy, because we want all the edges to be bathed in that chemotherapy. Then, after we’ve drained it all out then we’ll put the plumbing back together, whatever we had to remove and then we take one more look and make sure everything looks clean and dry and then we get of there and close the abdomen.
Melanie: At what point do you know that it is working for the patient? Is there a way that you can tell whether or not whether it got into those nooks and crannies? And we don’t have a lot of time, Dr. Flynn, but speak about what happens after HIPEC for the patient and what you would like other physicians to know about this as a treatment option, and when to refer.
Dr. Flynn: OK, absolutely. So what we do, after we do the surgery, we follow them up. Sometimes their hospital courses can be relatively long, we’re talking maybe up to a couple weeks is usually the average time, maybe a little bit less, just depending on how much cancer they had there, and after that, we just follow them. They do traditionally go back on chemotherapy, but the advantage of doing this debulking or cytoreductive surgery and the HIPEC is that now instead of traditionally these patients being opened and closed and going on chemotherapy indefinitely until they can’t tolerate it any more, or it stops working, we by doing this procedure extirpate all the cancer and now there’s light at the end of the tunnel for these patients because now once we have gotten it all out, then they need a short course of chemotherapy relatively speaking, and then, after that, they’re free unless the cancer comes back. So then we follow them with serial CAT scans every 3 months and then we get to every 6 months and ultimately, yearly.
So the take home message is that for this subset of patients that previously was told they had no hope and that they would be on chemotherapy indefinitely, we are now able to provide patients with an alternative to that, which begins with hope and in a subset of patients that are selected carefully, we can prevent them from dying of the classic sequelae that they do in these particular cancers which is bowel obstruction for patients they get cancer all over, you’re not able to get it out, they are on chemotherapy, and then there bowels block, and then they die of pretty much vomiting, abdominal pain, bloating and starvation.
So, if we can keep that cancer out of their abdomen for as long as possible, then we’ve won in that particular case, we’ve beaten that disease, and that’s what we look for – the home run.
Melanie: Thank you so much Dr. Flynn, for being with us today, it is really great information and such an amazing technique. You are listening to Expert Insights – Physicians Views and News with the Christ Hospital Network. More information on Dr. Flynn and all the Christ Hospital physicians is available at tchpconnect.org. This is Melanie Cole – thank you so much for listening.
Introduction To Dr. Rod Flynn and HIPEC Treatments
Melanie Cole (Host): The Christ Hospital Network is proud to welcome Dr. Rod Flynn. Dr. Flynn is a Surgical Oncologist and brings extensive experience and a new treatment focus to the Christ Hospital Health Network. We’re going to be discussing HIPEC today, or hyperthermic intraperitoneal chemotherapy. Welcome to the show, Dr. Flynn. Let’s start by telling us a little bit about yourself and your philosophy of care.
Dr. Rod Flynn (Guest): Thank you very much for having me here today. My name is Rod Flynn and I’ve been in practice for about 14 years and for the last 9 of those years I’ve been focusing specifically on cancer. I received my Fellowship in Surgical Oncology in 2004 at the University of Pittsburgh and that is where I became enamored with the concept of Cytoreductive surgery and HIPEC, the reason being because this is a disease process that has been traditionally known as the “open and close” where the patient has some form of GI malignancy and they are taken to the operating room for a resection of their primary tumor and the patient gets opened up and the patient is found to have an Inordinate amount of cancer there and they are closed back up and they are told that nothing can be done other than chemotherapy and then they are given just a globally poor prognosis and so with this technique of cytoreductive surgery and HIPEC we are able to provide patients, on the contrary instead of being given essentially a death sentence, we’ve been able to give them hope that they would not have imagined that they would have had prior to the advent of this technique.
Melanie: So what are the types of cancer that you are looking at that HIPEC could be used for?
Dr. Flynn: Well it was used in the 1980’s for cancer of the appendix. There are 2 major categories. One of them is what we call pseudomyxoma peritonii which is a very bland type of mucinous debris that usually emanates from an appendix that has ruptured and it disseminates this mucinous or jelly like substance within the abdominal cavity and a lot of people would call that “Jelly belly” and so in the 1980’s the technique of debulking or what we now call cytoreduction which means reduction of cells or destruction or elimination of cells so I use the term cytoreduction synonymously with debulking.
So back in the 80’s these appendiceal tumors were treated with cytoreduction surgery and intraperitoneal chemotherapy and what they were finding was that patients could live literally decades without a significant recurrence of their disease, so that has been kind of the model that has been used since that time and it has been extrapolated to many other types of malignancies including, colon, stomach cancer and also this rare disease called diffuse malignant intraperitoneal mesothelioma. You hear a lot of that mesothelioma hype when it comes to lung cancer and the exposure to asbestos, but it turns out that the same kind of membrane that lines the lungs also lines the abdominal or peritoneal cavity, so you can see mesothelioma of the abdomen and actually HIPEC works quite well with that particular disease process as well. And also a bit more controversial is use in ovarian cancer, because what you find in ovarian cancer is that about 75% patients present with a disseminated form of this disease, which it is almost as if the tumor exploded in the abdomen and traditionally that has been treated with debulking and intravenous chemotherapy but again, we believe in the
In the HIPEC world, that HIPEC should also be considered in these patients, at least for their recurrences, after they have been treated with debulking and intravenous chemotherapy.
Melanie: So these are cancers that have spread to the lining surfaces of the abdominal cavity from other types of abdominal cancers but have not yet spread outside that peritoneal cavity?
Dr. Flynn: Correct.
Melanie: So explain to the listeners a little bit about what HIPEC actually is and how this heat, this type of chemotherapy works in conjunction with the surgery and cytoreduction surgery you were just discussing.
Dr. Flynn: Absolutely, so again, real quickly, the mechanism of what we see is first of all the diagnosis of what we call “Carcinomatosis”, or peritoneal metastases, and what you alluded to, what basically happens is, just imagine an intra-abdominal organ like say the stomach. What happens is that these cancers grow on the inner lining of the stomach or these other intra-abdominal organs, and what happens is in a lot of cases they will grow radially from the inside and kind of push their way to the outer surface of that organ and then from there it’s as if the cancer just explodes and it drops these implants throughout the abdominal or peritoneal cavity.
For the lack of a better metaphor I always refer to that peritoneal lining is like a trash bag that lines a trash can, and so imagine a tumor exploding if you will, and seeding all over that lining, and so that’s kind of the mechanism of what happens.
And so, in our technique, what we do, we don’t just open and close those patients. Often times we get those patients on referral, after they have been opened and closed, and by the way, a lot of people say that once the air hits it, it goes haywire and that’s really an old myth and is not how these cancers work.
Anyway at that point we would see the patient and do our own assessment to make sure they are a candidate, and by the way I will talk a little bit about that later, and if the still fit the description, we take them to the operation room with the express intention of removing all the visible disease, and that means not just the primary, so if it is a stomach cancer, we remove the part of the stomach that is involved, but then we explore the entire abdominal cavity, and any area that is peppered with these nodules we will remove. If a piece of organ has a confluence of these nodules, then we resect a piece of that organ. For example, the spleen is often just lined with these cells and we have to remove those. Sometimes the small intestine and what we call the greater omentum, which is this fatty apron that drapes the abdomen, and other areas, so our goal is to remove all visible tumor.
The other thing I would mention is that a lot of times we get these patients after they have already had multiple operations so we must begin when we get into the abdomen by lysing or dividing all the scar tissue to expose literally every surface of the abdominal cavity. That’s important, because later, when we distribute the chemotherapy, we want it to hit every nook and cranny.
So, anyway, we go in there and we remove all the visible cancer that’s there, and this can take anywhere from 5 hours to – my longest has been 17 and a half hours and painstakingly go through every nook and cranny of the abdominal cavity and try to remove all the visible tumor, and once we’ve done that, then we apply this heated chemotherapy. What we do is almost like a heart bypass circuit, where we hook them up to this machine and we bring a tubing that goes from the patient to the machine, and then there is a second set of tubing that goes from the machine back to the patient, so we circulate a fluid – usually about 3 liters to 3 ½ liters of fluid – we do this to heat their body up to a certain temperature between 41 and 41 ½ degrees centigrade, and then, once we’ve got their body to that steady state temperature then we apply the chemotherapy. And then what we do is close just the skin, leave those catheters in there and we do what’s called a “shake and bake”, so we just manually with our hands jostle the abdomen a little bit to get all that chemotherapy distributed. This process alone takes about 90 minutes, some people do 100 minutes, in our institution we’ve done it traditionally for 90 minutes, then we undo the skin sutures, drain all the chemotherapy out, and then, if we’ve resected a piece of, say, intestines, like a piece of pipe, say we had a bad pipe, we take a piece out, and ultimately we’re going to splice the pipe back together, well we leave the piece out when we’re doing the chemotherapy, because we want all the edges to be bathed in that chemotherapy. Then, after we’ve drained it all out then we’ll put the plumbing back together, whatever we had to remove and then we take one more look and make sure everything looks clean and dry and then we get of there and close the abdomen.
Melanie: At what point do you know that it is working for the patient? Is there a way that you can tell whether or not whether it got into those nooks and crannies? And we don’t have a lot of time, Dr. Flynn, but speak about what happens after HIPEC for the patient and what you would like other physicians to know about this as a treatment option, and when to refer.
Dr. Flynn: OK, absolutely. So what we do, after we do the surgery, we follow them up. Sometimes their hospital courses can be relatively long, we’re talking maybe up to a couple weeks is usually the average time, maybe a little bit less, just depending on how much cancer they had there, and after that, we just follow them. They do traditionally go back on chemotherapy, but the advantage of doing this debulking or cytoreductive surgery and the HIPEC is that now instead of traditionally these patients being opened and closed and going on chemotherapy indefinitely until they can’t tolerate it any more, or it stops working, we by doing this procedure extirpate all the cancer and now there’s light at the end of the tunnel for these patients because now once we have gotten it all out, then they need a short course of chemotherapy relatively speaking, and then, after that, they’re free unless the cancer comes back. So then we follow them with serial CAT scans every 3 months and then we get to every 6 months and ultimately, yearly.
So the take home message is that for this subset of patients that previously was told they had no hope and that they would be on chemotherapy indefinitely, we are now able to provide patients with an alternative to that, which begins with hope and in a subset of patients that are selected carefully, we can prevent them from dying of the classic sequelae that they do in these particular cancers which is bowel obstruction for patients they get cancer all over, you’re not able to get it out, they are on chemotherapy, and then there bowels block, and then they die of pretty much vomiting, abdominal pain, bloating and starvation.
So, if we can keep that cancer out of their abdomen for as long as possible, then we’ve won in that particular case, we’ve beaten that disease, and that’s what we look for – the home run.
Melanie: Thank you so much Dr. Flynn, for being with us today, it is really great information and such an amazing technique. You are listening to Expert Insights – Physicians Views and News with the Christ Hospital Network. More information on Dr. Flynn and all the Christ Hospital physicians is available at tchpconnect.org. This is Melanie Cole – thank you so much for listening.