HIPEC, or heated intraoperative peritoneal chemotherapy, is an alternative method of delivering chemotherapy. Instead of infusing the medications through a vein, the chemotherapy is circulated in the abdominal cavity at the time of surgery. This allows direct treatment of certain cancers which have spread throughout the abdomen.
At City of Hope, our peritoneal surface malignancy team consists of a multidisciplinary group of experts in the field. We are one of the busiest HIPEC centers in Southern California, and continue to push the envelope in treating these difficult cancers. The team will evaluate your case and present options. Not everyone will be a candidate for HIPEC and aggressive surgery, but other treatments may be available.
Byrne Lee, M.D is here to explain how studies are showing that HIPEC with aggressive surgery improves survival in some cancers when compared to chemotherapy alone.
Selected Podcast
Heated Intraperitoneal Chemotherapy (HIPEC): Treating Difficult Cancers
Featured Speaker:
At City of Hope, Dr. Lee leads the surgical team of the peritoneal surface malignancy and heated intraperitoneal chemotherapy program.His expertise in cytoreductive (tumor debulking) surgical procedures has helped our program become one of the most successful in the nation.
Learn more about Byrne Lee, M.D
Byrne Lee, MD
Byrne Lee, M.D., rejoined City of Hope in 2013 with a focus on the treatment of gastrointestinal, pancreatic and liver cancers. He routinely utilizes minimally invasive approaches such as robotic and laparoscopic techniques.At City of Hope, Dr. Lee leads the surgical team of the peritoneal surface malignancy and heated intraperitoneal chemotherapy program.His expertise in cytoreductive (tumor debulking) surgical procedures has helped our program become one of the most successful in the nation.
Learn more about Byrne Lee, M.D
Transcription:
Heated Intraperitoneal Chemotherapy (HIPEC): Treating Difficult Cancers
Melanie Cole (Host): HIPEC, or heated intraoperative peritoneal chemotherapy, is an alternative method of delivering chemotherapy. Instead of infusing the medications through a vein, the chemotherapy is circulated in the abdominal cavity at the time of surgery. My guest today is Dr. Byrne Lee. He’s the Chief in the Mixed Tumor Surgery Service and Assistant Clinical Professor in the Division of Surgical Oncology at City of Hope. Welcome to the show. Dr. Lee, let’s discuss HIPEC. Tell the listeners what this is versus standard chemotherapy that they’ve heard so much about.
Dr. Byrne Lee (Guest): So, HIPEC is a way of delivering chemotherapy that’s different than the standard way. Essentially when we are dealing with cancers that invade the abdominal cavity, we know that giving chemotherapy by the vein is effective but it’s a hard place for that chemotherapy to sink in and destroy the cancer cells. HIPEC was developed almost 20 years ago and, essentially, the thought was when surgeons are in the operating room, could we help deliver chemotherapy to the cells at hand. So, essentially, when we’re in there and we see the cancer cells floating around, we know that there’s still going to be cancer cells left behind when we’re done with our surgery. Was there a way that we could potentially deliver chemotherapy to be more effective at the site? And, essentially, that’s what it is. When we’re in the operating room, after we’re done with a large surgery to remove abdominal tumors, we place catheters and we infuse the chemotherapy and, again, this is a different way of delivering chemotherapy that allows us to hit the cancer cells at their site of metastasis.
Melanie: Which cancers can be treated with HIPEC, typically?
Dr. Lee: The typical cancers that we see for HIPEC evaluation, those are going to be colon cancers, appendiceal cancers and ovarian cancers. At City of Hope, we do see other cancers that typically metastasize to the abdominal cavity and that’s going to be stomach cancers, mesothelioma, and something called “primary peritoneal cancers”. Certain patients are candidates for HIPEC treatment and we evaluate them for the treatments at City of Hope.
Melanie: So, tell us about the heated part of it because people hear that and they think, “Is like ablation?” Are you burning something? How hot is it? What exactly happens?
Dr. Lee: So, in the operating room, the chemotherapy is heated to about 42 degrees Celsius, that equates to about a temperature of 105 degrees Fahrenheit. The heat does several things. One, we believe that it does kill the cancer cells on hand. Our normal cells have the ability to repair themselves after such a heat shock. Most cancer cells can't repair themselves. So, when they are heated to that temperature, we do see a decline in the numbers and we believe that the cancer cells are actually dying from the heat effect itself. Additionally, chemotherapy will work better when heated, and I think that is the main draw or the main reason why we heat the perfusion because it does allow the chemotherapy to penetrate the cancer cells and be more effective in that way. That’s essentially why we use heat in the operating room.
Melanie: So, does this allow for higher doses of chemotherapy, and is it a one time shot because people think of chemotherapy as coming in once a month, sitting in there for three hours, in the standard form. But, this you’re doing while you’re in the operating room.
Dr. Lee: Correct. And that’s an excellent question. The one time treatment is, that is correct. When we do heated intra-peritoneal chemotherapy, it is a one-time treatment. It basically is done at the time of the debulking surgery and, as I said, the idea is we don’t necessarily do HIPEC unless we know that we have adequately removed all of the abdominal tumors. So, the addition of the large surgery to bring down what we see and then the addition of the HIPEC treatment in the operating room, we believe that that is essential and beneficial to the patient, and that’s a one-time treatment. We do repeat HIPEC treatments when we see return of the cancer. That we have done several times and there are multiple studies out there showing that it can be done safely but, again, it’s in highly selected patients and patients that we know who have benefited from HIPEC in the past, we generally will offer it to them again if we think it’s a reasonable treatment. The question about dosage of chemotherapy. When we perform peritoneal chemotherapy, we can deliver the drug at a higher dose and the reason is because most of that chemotherapy will stay in the abdominal cavity. That’s a benefit because if we were to give these doses through the vein, the side effects would be too much, too toxic. So, when we deliver it in the abdominal cavity, the dosage is going to be higher so the effect in killing cancer cells is going to be higher and the systemic effect is less because less of it will be absorbed.
Melanie: So, there is less side effects. People think of those side effects, Dr. Lee, with chemotherapy and since this done right after cytoreductive surgery and it’s this higher dose that stays in the abdominal cavity, are they going to experience some of those similar side effects--hair loss, nausea--any of those with HIPEC?
Dr. Lee: I don’t see as much of the hair loss that we see with systemic chemotherapy and, generally, I say that that side effect we rarely see with this treatment. The nausea, I do see that and I relate that more to the cytoreductive surgery than the actual chemotherapy or the heat. As we are doing these surgeries, they affect a large amount of the abdominal cavity. We are searching every corner and turning over the abdominal organs in order to visualize where there are potential cancer cells hiding or tumors hiding and that’s what I feel creates quite a bit of nausea in the post-surgery setting. But, the systemic effects such as the drop in the blood count, the hair loss, the fatigue, we don’t see that so much with HIPEC therapy.
Melanie: So, what else would you like them to know about HIPEC therapy, the advantages, and are there any disadvantages?
Dr. Lee: I believe the advantage is this: before we were doing cytoreductive surgery and HIPEC for tumors that metastasized to the abdominal cavity or peritoneal cavity, systemic chemotherapy was not providing a huge survival advantage. In fact, most of these patients were just treated as palliative cases. When we started doing cytoreduction, we did see improvements in survival but they still were not very good. And I think the package, the addition of surgery and chemotherapy in the operating room, has now changed the way we look at this disease. We don’t look at it so much as a terminal disease anymore, we look at it as a potential treatment. Almost like my colleagues that do liver surgery for metastasis, we look at this the same way. We look at it as a metastasis that we can treat and we have effective therapies for these patients at this time.
Melanie: In just the last few minutes, please tell us about your team at City of Hope and this multidisciplinary team of experts, and that you’re one of the busiest HIPEC centers in Southern California. Tell us a little bit about that.
Dr. Lee: City of Hope has always been a special center. We basically are Los Angeles but not in Los Angeles. A lot of our patients do travel quite far, quite a distance, to come and see us. I think one of our strong points is the multidisciplinary team. We have doctors in medical oncology, radiation oncology, surgical oncology and all these experts come together, review each case, and we decide what are the best treatments. Not every patient is going to benefit from HIPEC. Some patients go on to get systemic chemotherapy first and then come back to our team of surgeons. That’s essentially one of the benefits here. It’s as if we can offer many roads, many pathways of therapy and, ultimately, we decide on what’s the best treatment. The surgeons here have great experience in cytoreduction. In fact, the team involves, not only myself but several other surgical oncologists, gynecological oncologists and colorectal surgeons. I think in terms of the team that we’ve put together, we’ve essentially become one of the biggest centers in southern California for HIPEC. I think one of the biggest draws is, again, that we have excellent physicians treating the patients; our outcomes are good; our ability to deliver the treatment safely has helped us gain this center of excellence.
Melanie: Thank you so much for being with us today. What a fascinating topic. You’re listening to City of Hope Radio. For more information, you can go to www.cityofhope.org. That’s www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Heated Intraperitoneal Chemotherapy (HIPEC): Treating Difficult Cancers
Melanie Cole (Host): HIPEC, or heated intraoperative peritoneal chemotherapy, is an alternative method of delivering chemotherapy. Instead of infusing the medications through a vein, the chemotherapy is circulated in the abdominal cavity at the time of surgery. My guest today is Dr. Byrne Lee. He’s the Chief in the Mixed Tumor Surgery Service and Assistant Clinical Professor in the Division of Surgical Oncology at City of Hope. Welcome to the show. Dr. Lee, let’s discuss HIPEC. Tell the listeners what this is versus standard chemotherapy that they’ve heard so much about.
Dr. Byrne Lee (Guest): So, HIPEC is a way of delivering chemotherapy that’s different than the standard way. Essentially when we are dealing with cancers that invade the abdominal cavity, we know that giving chemotherapy by the vein is effective but it’s a hard place for that chemotherapy to sink in and destroy the cancer cells. HIPEC was developed almost 20 years ago and, essentially, the thought was when surgeons are in the operating room, could we help deliver chemotherapy to the cells at hand. So, essentially, when we’re in there and we see the cancer cells floating around, we know that there’s still going to be cancer cells left behind when we’re done with our surgery. Was there a way that we could potentially deliver chemotherapy to be more effective at the site? And, essentially, that’s what it is. When we’re in the operating room, after we’re done with a large surgery to remove abdominal tumors, we place catheters and we infuse the chemotherapy and, again, this is a different way of delivering chemotherapy that allows us to hit the cancer cells at their site of metastasis.
Melanie: Which cancers can be treated with HIPEC, typically?
Dr. Lee: The typical cancers that we see for HIPEC evaluation, those are going to be colon cancers, appendiceal cancers and ovarian cancers. At City of Hope, we do see other cancers that typically metastasize to the abdominal cavity and that’s going to be stomach cancers, mesothelioma, and something called “primary peritoneal cancers”. Certain patients are candidates for HIPEC treatment and we evaluate them for the treatments at City of Hope.
Melanie: So, tell us about the heated part of it because people hear that and they think, “Is like ablation?” Are you burning something? How hot is it? What exactly happens?
Dr. Lee: So, in the operating room, the chemotherapy is heated to about 42 degrees Celsius, that equates to about a temperature of 105 degrees Fahrenheit. The heat does several things. One, we believe that it does kill the cancer cells on hand. Our normal cells have the ability to repair themselves after such a heat shock. Most cancer cells can't repair themselves. So, when they are heated to that temperature, we do see a decline in the numbers and we believe that the cancer cells are actually dying from the heat effect itself. Additionally, chemotherapy will work better when heated, and I think that is the main draw or the main reason why we heat the perfusion because it does allow the chemotherapy to penetrate the cancer cells and be more effective in that way. That’s essentially why we use heat in the operating room.
Melanie: So, does this allow for higher doses of chemotherapy, and is it a one time shot because people think of chemotherapy as coming in once a month, sitting in there for three hours, in the standard form. But, this you’re doing while you’re in the operating room.
Dr. Lee: Correct. And that’s an excellent question. The one time treatment is, that is correct. When we do heated intra-peritoneal chemotherapy, it is a one-time treatment. It basically is done at the time of the debulking surgery and, as I said, the idea is we don’t necessarily do HIPEC unless we know that we have adequately removed all of the abdominal tumors. So, the addition of the large surgery to bring down what we see and then the addition of the HIPEC treatment in the operating room, we believe that that is essential and beneficial to the patient, and that’s a one-time treatment. We do repeat HIPEC treatments when we see return of the cancer. That we have done several times and there are multiple studies out there showing that it can be done safely but, again, it’s in highly selected patients and patients that we know who have benefited from HIPEC in the past, we generally will offer it to them again if we think it’s a reasonable treatment. The question about dosage of chemotherapy. When we perform peritoneal chemotherapy, we can deliver the drug at a higher dose and the reason is because most of that chemotherapy will stay in the abdominal cavity. That’s a benefit because if we were to give these doses through the vein, the side effects would be too much, too toxic. So, when we deliver it in the abdominal cavity, the dosage is going to be higher so the effect in killing cancer cells is going to be higher and the systemic effect is less because less of it will be absorbed.
Melanie: So, there is less side effects. People think of those side effects, Dr. Lee, with chemotherapy and since this done right after cytoreductive surgery and it’s this higher dose that stays in the abdominal cavity, are they going to experience some of those similar side effects--hair loss, nausea--any of those with HIPEC?
Dr. Lee: I don’t see as much of the hair loss that we see with systemic chemotherapy and, generally, I say that that side effect we rarely see with this treatment. The nausea, I do see that and I relate that more to the cytoreductive surgery than the actual chemotherapy or the heat. As we are doing these surgeries, they affect a large amount of the abdominal cavity. We are searching every corner and turning over the abdominal organs in order to visualize where there are potential cancer cells hiding or tumors hiding and that’s what I feel creates quite a bit of nausea in the post-surgery setting. But, the systemic effects such as the drop in the blood count, the hair loss, the fatigue, we don’t see that so much with HIPEC therapy.
Melanie: So, what else would you like them to know about HIPEC therapy, the advantages, and are there any disadvantages?
Dr. Lee: I believe the advantage is this: before we were doing cytoreductive surgery and HIPEC for tumors that metastasized to the abdominal cavity or peritoneal cavity, systemic chemotherapy was not providing a huge survival advantage. In fact, most of these patients were just treated as palliative cases. When we started doing cytoreduction, we did see improvements in survival but they still were not very good. And I think the package, the addition of surgery and chemotherapy in the operating room, has now changed the way we look at this disease. We don’t look at it so much as a terminal disease anymore, we look at it as a potential treatment. Almost like my colleagues that do liver surgery for metastasis, we look at this the same way. We look at it as a metastasis that we can treat and we have effective therapies for these patients at this time.
Melanie: In just the last few minutes, please tell us about your team at City of Hope and this multidisciplinary team of experts, and that you’re one of the busiest HIPEC centers in Southern California. Tell us a little bit about that.
Dr. Lee: City of Hope has always been a special center. We basically are Los Angeles but not in Los Angeles. A lot of our patients do travel quite far, quite a distance, to come and see us. I think one of our strong points is the multidisciplinary team. We have doctors in medical oncology, radiation oncology, surgical oncology and all these experts come together, review each case, and we decide what are the best treatments. Not every patient is going to benefit from HIPEC. Some patients go on to get systemic chemotherapy first and then come back to our team of surgeons. That’s essentially one of the benefits here. It’s as if we can offer many roads, many pathways of therapy and, ultimately, we decide on what’s the best treatment. The surgeons here have great experience in cytoreduction. In fact, the team involves, not only myself but several other surgical oncologists, gynecological oncologists and colorectal surgeons. I think in terms of the team that we’ve put together, we’ve essentially become one of the biggest centers in southern California for HIPEC. I think one of the biggest draws is, again, that we have excellent physicians treating the patients; our outcomes are good; our ability to deliver the treatment safely has helped us gain this center of excellence.
Melanie: Thank you so much for being with us today. What a fascinating topic. You’re listening to City of Hope Radio. For more information, you can go to www.cityofhope.org. That’s www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.