HIPEC, or hyperthermic intraperitoneal chemotherapy, is given immediately after a peritonectomy or cytoreductive surgery, while the patient is still in the operating room.
The chemotherapy drugs are heated to make them more potent, then used to directly bathe the surgical site in the abdomen. This method kills any remaining cancer cells and provides higher, more effective doses of medication, without significantly affecting the rest of the body.
Listen in as Chukwuemeka U. Ihemelandu, MD, discusses which patients are the best candidates, when to make referrals and how outcomes advance this procedure.
Selected Podcast
Hyperthermic Intraperitoneal Chemotherapy
Featured Speaker:
Learn more about Chukwuemeka Ihemelandu, MD
Chukwuemeka U. Ihemelandu, MD
Chukwuemeka Ihemelandu, MD, is a board-certified surgical oncologist at MedStar Washington Hospital Center. He is Assistant Professor of Surgical Oncology at Georgetown University Medical School and is a member of the Society of Surgical Oncology (SSO) as well as the Society of Surgery for the Alimentary Tract (SSAT). Dr. Ihemelandu specializes in the treatment of peritoneal carcinomatosis, or cancer of the abdomen, through the use of cytoreductive surgery and intraoperative chemotherapy. He also specializes in the treatment of gastric cancer, sarcoma and pancreatic cancer. His clinical interests include advanced abdominal cancers. His research interests include analyzing the use of near-infrared fluorescent technology to look for microscopic cancer during surgery to aid in the complete removal of a disease. He is also analyzing the molecular profile of unique tumors in the abdomen to understand how treatment can be personalized for each patient.Learn more about Chukwuemeka Ihemelandu, MD
Transcription:
Hyperthermic Intraperitoneal Chemotherapy
Melanie Cole (Guest): Hyperthermic intraperitoneal chemotherapy is one of the most innovative treatments available today for complex abdominal cancers. My guest today is Dr. Chukwuemeka Ihemelandu. He’s a board certified surgical oncologist at MedStar Washington Hospital Center. Welcome to the show, Doctor. Tell us about HIPEC, what exactly this procedure is and who are the best candidates for it?
Dr. Chukwuemeka Ihemelandu (Host): HIPEC, as you mentioned, stands for Hyperthermic, which is also called “heated”, Intraperitoneal means the chemotherapy is placed into the abdominal cavity, chemotherapy. And the whole idea behind it is for patients who have metastatic disease from either appendix cancer, colon cancer, gastric cancer and ovarian cancer. So, these patients, a couple of years ago, would have been told that there was no other option for them. We have an option for them including cytoreductive surgery, which basically involves going in there and taking out all the tumor cells that we can see with the naked eye and then treating the microscopic cells, those are the cells we can’t see with the naked eye, that are left behind with the intraperitoneal chemotherapy, the HIPEC. And so, this innovative approach is best for patients with peritoneal metastasis whether from appendix cancer, or colon cancer, gastric cancer or ovarian cancer.
Melanie: So, with this process your heating the chemotherapy drugs, and are you doing this right after surgery into the abdomen?
Dr. Ihemelandu: The process is actually done in between the procedure. So the cases would take anywhere from 10 to 12 hours and we would start off by the resection, meaning taking out of the disease that we see, and then we run the chemotherapy. It’s usually run for 90 minutes during the case, and after we’ve completed the chemotherapy, we then do our putting together of the anastomosis and any other repair that we have to do. And so, in answer to your question, yes, the chemotherapy is done at the time of surgery.
Melanie: Is this injected into an IV line or is this added to the drugs or added to a heated saline? How do you use it?
Dr. Ihemelandu: The drugs for the heated intraperitoneal chemotherapy are given through a device, it’s a machine that heats the chemotherapy and then it’s circulated through a circuit into the abdominal cavity. So, the chemotherapy is not going through the vein, it doesn’t go into the artery, it goes into the abdominal cavity and is circuited by the machine through the circuit for 90 minutes after which we then drain the chemotherapy from the abdominal cavity.
Melanie: What are some of the benefits to the patient and what is their after like?
Dr. Ihemelandu: The benefits include, one, we’re able to give the patient a much higher dose of the chemotherapy than the patients could possibly receive IV, intravenously. Also, we are able to place the chemotherapy directly on the site of the disease. When patients are given systemic chemotherapy, literature tells us that only about 15-20% of the systemic chemotherapy actually gets absorbed into the abdominal cavity. So, very little of the internal abdominal cavity is exposed to that systemic chemotherapy. And so, part of the advantage for the patient is that we’re able to expose the intra-abdominal cavity with the peritoneal metastasis to this chemotherapy. So, there is direct contact. And the other benefit is that there are very little, minimal side effects to the patient. They usually don’t lose their hair. A couple of them might have bone marrow suppression, but it’s very transient. It happens 4 to 5 days after administration of the chemotherapy, but they bounce back pretty quickly.
Melanie: Tell us about some of the outcomes you’ve had using this and maybe some of the challenges regarding the establishment of this as a standard of care.
Dr. Ihemelandu: I will start by talking about the challenges. I guess one of the biggest challenges that for anything to be accepted in the medical community we’re always looking for a randomized trial. Unfortunately, there’s been only one randomized trial looking at the benefits of this high-tech cytoreductive surgery and that was carried out in Europe. Attempts have been made to that in the United States but it’s very hard to get a patient to agree to get randomized into the cytoreductive surgery versus just surgery along with palliative care. And so, that study hasn’t been done, probably will never be done, and so we’re left with case studies--individual institutions reporting their outcomes. We’ve had very good outcomes for our patients, most especially patients will present with appendix cancer, currently patients who present with low-grade appendix cancer. We don’t talk about 5 year survivals. In fact, we’re talking about 10 year survivals, and that’s the range of 80-85%, which is actually outstanding, when you think back to about ten or twenty years ago this was not the case. We’ve also had very good outcomes with patients with colon cancer, with peritoneal metastasis. I actually have a very great story about a young man who was told there was no other option for him because he had liver metastases and he had peritoneal metastasis, and he came to us and we took him about 3 years ago he underwent the cytoreductive surgery with intraop chemotherapy, and he is disease-free three years out now. So, these are a few of the outstanding results we’ve had. We’ve also had great results with patients who present with ovarian cancer and we treat them with intraop chemotherapy.
Melanie: So, where there is a pharmacokinetic benefit and that tumor penetration is very specific, what is it like after the fact for the patient? Do they feel that heat going in?
Dr. Ihemelandu: The patients actually do not feel the heat. At the time of surgery, they actually are asleep as expected because they’re intubated. If you think about it, they lose of a lot of heat when they are undergoing surgery. So, if anything, our heated chemotherapy actually is beneficial to them because it heats up their core temperature. So, there’s no downside, at least we’ve not seen any downside to the heated chemotherapy. And, the highest temperature we usually go to is about 42 degrees Fahrenheit and it’s very tolerated by the patients with no overt side effects that we’ve seen. We’ve reported extensively on the morbidity of this procedure, which is always a concern for the acceptance of such an aggressive approach to cancer. But our morbidity rates have decreased as we’ve gotten better at the technical aspects of doing the case.
Melanie: So, doctor, in just these last few minutes wrap it up for us, for physicians, in what you have found in this innovative and complex approach to advanced intra-abdominal malignancies. Tell us what you want them to know.
Dr. Ihemelandu: What I would like my colleagues to know out there is that for patients who are diagnosed with what we typically would call a Stage 4 disease, and these are patients who have disease confined to their abdomen, what we also call “peritoneal metastasis,” that there is an option for them that actually offers them survival benefits. We’re so much better at this procedure and we have very minimal or acceptable morbidity rates. And, most importantly, we have very outstanding survivor benefits to the patients. So, I will encourage them that, if they do have a patient who meets this criteria having been diagnosed with recurrent colon cancer with metastasis, appendix cancer with peritoneal metastasis, ovarian cancer with peritoneal metastasis, or gastric cancer with peritoneal metastasis, to send the patient to us. We’re a center of excellence for peritoneal metastasis malignancy. Our center was actually the first in the United States and we actually have the largest data set and the most extensive experience with this procedure. And, we’ve documented this in multiple publications that we’ve got great outcomes for these patients. So, I encourage my colleagues to offer these patients these benefits and send them over to our center.
Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org. This is Melanie Cole. Thanks for listening.
Hyperthermic Intraperitoneal Chemotherapy
Melanie Cole (Guest): Hyperthermic intraperitoneal chemotherapy is one of the most innovative treatments available today for complex abdominal cancers. My guest today is Dr. Chukwuemeka Ihemelandu. He’s a board certified surgical oncologist at MedStar Washington Hospital Center. Welcome to the show, Doctor. Tell us about HIPEC, what exactly this procedure is and who are the best candidates for it?
Dr. Chukwuemeka Ihemelandu (Host): HIPEC, as you mentioned, stands for Hyperthermic, which is also called “heated”, Intraperitoneal means the chemotherapy is placed into the abdominal cavity, chemotherapy. And the whole idea behind it is for patients who have metastatic disease from either appendix cancer, colon cancer, gastric cancer and ovarian cancer. So, these patients, a couple of years ago, would have been told that there was no other option for them. We have an option for them including cytoreductive surgery, which basically involves going in there and taking out all the tumor cells that we can see with the naked eye and then treating the microscopic cells, those are the cells we can’t see with the naked eye, that are left behind with the intraperitoneal chemotherapy, the HIPEC. And so, this innovative approach is best for patients with peritoneal metastasis whether from appendix cancer, or colon cancer, gastric cancer or ovarian cancer.
Melanie: So, with this process your heating the chemotherapy drugs, and are you doing this right after surgery into the abdomen?
Dr. Ihemelandu: The process is actually done in between the procedure. So the cases would take anywhere from 10 to 12 hours and we would start off by the resection, meaning taking out of the disease that we see, and then we run the chemotherapy. It’s usually run for 90 minutes during the case, and after we’ve completed the chemotherapy, we then do our putting together of the anastomosis and any other repair that we have to do. And so, in answer to your question, yes, the chemotherapy is done at the time of surgery.
Melanie: Is this injected into an IV line or is this added to the drugs or added to a heated saline? How do you use it?
Dr. Ihemelandu: The drugs for the heated intraperitoneal chemotherapy are given through a device, it’s a machine that heats the chemotherapy and then it’s circulated through a circuit into the abdominal cavity. So, the chemotherapy is not going through the vein, it doesn’t go into the artery, it goes into the abdominal cavity and is circuited by the machine through the circuit for 90 minutes after which we then drain the chemotherapy from the abdominal cavity.
Melanie: What are some of the benefits to the patient and what is their after like?
Dr. Ihemelandu: The benefits include, one, we’re able to give the patient a much higher dose of the chemotherapy than the patients could possibly receive IV, intravenously. Also, we are able to place the chemotherapy directly on the site of the disease. When patients are given systemic chemotherapy, literature tells us that only about 15-20% of the systemic chemotherapy actually gets absorbed into the abdominal cavity. So, very little of the internal abdominal cavity is exposed to that systemic chemotherapy. And so, part of the advantage for the patient is that we’re able to expose the intra-abdominal cavity with the peritoneal metastasis to this chemotherapy. So, there is direct contact. And the other benefit is that there are very little, minimal side effects to the patient. They usually don’t lose their hair. A couple of them might have bone marrow suppression, but it’s very transient. It happens 4 to 5 days after administration of the chemotherapy, but they bounce back pretty quickly.
Melanie: Tell us about some of the outcomes you’ve had using this and maybe some of the challenges regarding the establishment of this as a standard of care.
Dr. Ihemelandu: I will start by talking about the challenges. I guess one of the biggest challenges that for anything to be accepted in the medical community we’re always looking for a randomized trial. Unfortunately, there’s been only one randomized trial looking at the benefits of this high-tech cytoreductive surgery and that was carried out in Europe. Attempts have been made to that in the United States but it’s very hard to get a patient to agree to get randomized into the cytoreductive surgery versus just surgery along with palliative care. And so, that study hasn’t been done, probably will never be done, and so we’re left with case studies--individual institutions reporting their outcomes. We’ve had very good outcomes for our patients, most especially patients will present with appendix cancer, currently patients who present with low-grade appendix cancer. We don’t talk about 5 year survivals. In fact, we’re talking about 10 year survivals, and that’s the range of 80-85%, which is actually outstanding, when you think back to about ten or twenty years ago this was not the case. We’ve also had very good outcomes with patients with colon cancer, with peritoneal metastasis. I actually have a very great story about a young man who was told there was no other option for him because he had liver metastases and he had peritoneal metastasis, and he came to us and we took him about 3 years ago he underwent the cytoreductive surgery with intraop chemotherapy, and he is disease-free three years out now. So, these are a few of the outstanding results we’ve had. We’ve also had great results with patients who present with ovarian cancer and we treat them with intraop chemotherapy.
Melanie: So, where there is a pharmacokinetic benefit and that tumor penetration is very specific, what is it like after the fact for the patient? Do they feel that heat going in?
Dr. Ihemelandu: The patients actually do not feel the heat. At the time of surgery, they actually are asleep as expected because they’re intubated. If you think about it, they lose of a lot of heat when they are undergoing surgery. So, if anything, our heated chemotherapy actually is beneficial to them because it heats up their core temperature. So, there’s no downside, at least we’ve not seen any downside to the heated chemotherapy. And, the highest temperature we usually go to is about 42 degrees Fahrenheit and it’s very tolerated by the patients with no overt side effects that we’ve seen. We’ve reported extensively on the morbidity of this procedure, which is always a concern for the acceptance of such an aggressive approach to cancer. But our morbidity rates have decreased as we’ve gotten better at the technical aspects of doing the case.
Melanie: So, doctor, in just these last few minutes wrap it up for us, for physicians, in what you have found in this innovative and complex approach to advanced intra-abdominal malignancies. Tell us what you want them to know.
Dr. Ihemelandu: What I would like my colleagues to know out there is that for patients who are diagnosed with what we typically would call a Stage 4 disease, and these are patients who have disease confined to their abdomen, what we also call “peritoneal metastasis,” that there is an option for them that actually offers them survival benefits. We’re so much better at this procedure and we have very minimal or acceptable morbidity rates. And, most importantly, we have very outstanding survivor benefits to the patients. So, I will encourage them that, if they do have a patient who meets this criteria having been diagnosed with recurrent colon cancer with metastasis, appendix cancer with peritoneal metastasis, ovarian cancer with peritoneal metastasis, or gastric cancer with peritoneal metastasis, to send the patient to us. We’re a center of excellence for peritoneal metastasis malignancy. Our center was actually the first in the United States and we actually have the largest data set and the most extensive experience with this procedure. And, we’ve documented this in multiple publications that we’ve got great outcomes for these patients. So, I encourage my colleagues to offer these patients these benefits and send them over to our center.
Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org. This is Melanie Cole. Thanks for listening.