Researchers at Roswell Park Comprehensive Cancer Center have determined that cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CS/HIPEC), a complex procedure to treat advanced abdominal cancers, can be done safely, and may be an effective therapy for select patients.
In this fascinating segment, Valerie Francescutti, MD., disusses Cytoreduction Surgery and Hyperthermic Intraperitoneal Chemotherapy as a way to improve survival, surgical outcomes, and when to refer to a specialist.
Selected Podcast
Understanding Cytoreduction/Hyperthermic Intraperitoneal Chemotherapy (CS/HIPEC)
Featured Speaker:
Learn more about Valerie Francescutti, MD
Valerie Francescutti, MD
Valerie Francescutti, MD joined the Surgical Oncology faculty at Roswell Park Comprehensive Cancer Center in 2012 as an Assistant Professor of Surgical Oncology in Soft Tissue and GI surgery.Learn more about Valerie Francescutti, MD
Transcription:
Understanding Cytoreduction/Hyperthermic Intraperitoneal Chemotherapy (CS/HIPEC)
Bill Klaproth (Host): Recent advances in cancer treatments such as Cytoreduction Hyperthermic Intraperitoneal Chemotherapy, or Cytoreduction and HIPEC, has proven to be an effective treatment option for certain late-stage gastrointestinal cancers. Here to help us learn more about Cytoreduction and HIPEC is Dr. Valerie Francescutti, Assistant Professor of Oncology, Department of Surgical Oncology at Roswell Park Comprehensive Cancer Center. Dr. Francescutti, thank you so much for your time. What is Cytoreduction and HIPEC?
Dr. Valerie Francescutti (Guest): Well, it’s a combined surgical procedure where initially, as the first portion of the procedure, an abdominal tumor or tumor nodules are removed. Once all or near all of the visible tumor has been removed by the surgeon, we administer warmed chemotherapy into the abdominal cavity while the patient is still under an anesthetic and the rationale for this chemotherapy is the microscopic tumor cells that may remain that cannot be removed by the surgical portion of the procedure. Those two combined portions of the procedure are done at one setting at one time, and the benefit really is that the chemotherapy that’s provided into the abdominal cavity after the cytoreduction is given directly to where the problem is, which is in the abdominal cavity. We can provide it both at a higher concentration than we would be able to by providing it intravenously like standard chemotherapies are given, and also, the patient absorbs less of it, so the toxicities from that higher dose is less.
Bill: So, how does this work? Is that because of the heat component?
Dr. Francescutti: Several different things. There’s heat, there’s perfusion pressures, and also, the actual character of the chemotherapy drug itself being sensitive to the particular types of tumors that it treats. One of the more common types of chemotherapy that we use in this procedure would be Mitomycin C. Other types of chemotherapy include Oxaliplatin, which is another common chemotherapy drug that’s used. Both of those are probably the two most common ones. At Roswell, we tend to use the Mitomycin C most frequently. It’s the best studied and has had very good response rates.
Bill: And what are the advantages of the HIPEC procedure?
Dr. Francescutti: In terms of being able to remove all of the visible tumors at the time of the surgery, we can specifically deal with everything that is there that could, in the future, let’s say, cause a bowel obstruction. We can also reduce the amount that’s left in the abdominal cavity of any tumor to a very small amount where the chemotherapy that’s administered after the surgical part of the procedure can actually deal with it, and we know that there is definitely tissue penetration of the chemotherapy that’s given into the abdominal cavity to manage it.
The other part of that which is very important from a patient quality of life perspective is many of these patients, in particular, ones that have colorectal cancers or appendix adenocarcinoma type cancers do need to have some IV or standard chemotherapy treatments, and this procedure often times can follow that treatment. Often times, if the tumor in the abdominal cavity can be dealt with completely – completely removed, then we can actually get patients off of systemic chemotherapy where they can have a break from needing to have systemic chemotherapy continuously. It’s a nice way to consolidate treatment and be off of treatments and onto more of a surveillance strategy for a period.
Bill: Right, so very important advancements. Which patients are good candidates for the HIPEC procedure?
Dr. Francescutti: First, I’ll describe the types of patients that would be good candidates. First, it’s really important to select a patient that overall, is fairly healthy, has either fewer or well-controlled comorbid conditions. Patients that have heart issues if they’re well-controlled, blood pressure well-controlled, diabetes well-controlled, and can also be able to tolerate a fairly lengthy anesthetic as part of the surgery and the associated recovery required from this procedure. That would be how I would define a good patient for the procedure.
There are also tumor factors, so the type of tumor that a patient has. The most common types of tumors that we treat with this procedure would be those of the GI tract, as I had described -- usually, colorectal cancer, appendix cancer, and the appendix tumors can come in more of a higher-grade adenocarcinoma or a lower grade type of neoplasm. Also, some of the gynecological cancers such as ovarian cancer, and then lastly, the less common types of tumors that start directly from the cells of the lining of the abdominal cavity. Those tumors are peritoneal mesothelioma or primary peritoneal cancers. Those are usually the best-treated tumors with this approach.
The important parts about the patients’ extent of disease is really something that we carefully consider both on imaging and prior operations. What’s important is to have a patient who has a tumor that’s confined to the abdominal cavity, so does not have any evidence of spread outside of the abdominal cavity – say, for example, no lung metastases, or lymph nodes in the chest, or what have you -- that are concerning for spread. Now, if the patient has had spread to a solid organ – an example of that would be liver metastasis – the hope there would either be that it is a fairly small metastasis – it’s fairly easily managed with a lower-risk surgery, or it potentially has already been managed by a surgery prior to the HIPEC procedure.
When we look at the amount of peritoneal nodules or spread in the abdominal cavity, the lower amount and size of these nodules the better, and certainly, that they are all resectable – that we’re able to remove all of it or near all of it to be able to make sure that the remaining tumor is going to be sensitive to the HIPEC part of the procedure.
And then the last thing is I think I had mentioned is that a patient has actually derived some benefit from other treatments such as the IV chemotherapy. To see a patient who has had some IV systemic chemotherapy and has had a good response, or at least a stable looking CT scan over the period of time that they’ve received the treatments is always something that describes a good candidate for this procedure.
Bill: And speaking of patient benefit, can you share with us patient experience before and after the procedure?
Dr. Francescutti: Well, I think it’s very difficult to describe sometimes because patients come from a variety of different settings. Some come after having been diagnosed with their tumors several years prior, and the peritoneal metastasis that they come with are part of a recurrence or the tumor having come back. Other patients, that’s how they originally present to their gastroenterologist or their internist with the tumor that had already spread. I think patients are coming from a variety of different settings, so it’s very difficult to get a handle on the experience itself. I think that it is a very complex surgical procedure to discuss and it really does involve a lot of preoperative preparation – physical therapy, nutrition. It does involve an in-hospital recovery period, which is usually anywhere from 7 to 14 days. And then also, the recovery at home, which, depending on the actual surgical procedure and what is done for the patient that can be 6 to 7 weeks or longer recovering at home.
From my personal experience with these patients, I think many of them are very overwhelmed with the amount of information that they get. I think we’re also not the first or the only physician to see that patient, so we are part of the team that will be managing them. We are spending a good amount of time getting to know the patients, getting to understand their choices, and also, hopefully, that they are having all the information and the education that they need to proceed with this surgery and that they’re committed to the recovery period and so forth. We're very attuned to the physical and emotional side-effects and then also, the more extended experience of the social, and financial, and spiritual effects that this very life-changing procedure can have on patients. We’re paying particular to that as it’s very life-changing often.
Bill: Speaking of hospital and recovery time, what is the long-term effectiveness of the HIPEC procedure?
Dr. Francescutti: I think that the best way to describe that would be looking at some of the studies in patients with colorectal cancer because those are the patients that had been studied the best. There’s at least one randomized-controlled trial that looked at patients that just had IV chemotherapy compared with the group that had the HIPEC procedure and then IV chemotherapy as well. In patients that just have IV chemotherapy – those are including the newer agents that are being used, targeted therapies, and fairly effective IV chemotherapy agents per the medical oncologists that see them. The five-year survival for this group of patients is about 10% -- maybe a little bit less than 10%. When we add in the HIPEC procedure -- that would be HIPEC plus the addition of the IV chemotherapy drugs that they may need to get before a procedure or after a procedure – that survival at five-years could increase up to 35%. That’s a big jump there – a big difference for these patients.
In addition to just the survival part of it, the chemotherapy provided into the abdominal cavity – the HIPEC portion – can also help to palliate some other symptoms such as fluid buildup in the abdominal cavity termed ascites. Symptomatic management of some of the symptoms that the patients are having can be helped with the HIPEC procedure as well.
Bill: Very good. Well, Dr. Francescutti, thank you so much for talking to us today about Cytoreduction and HIPEC. For more information, you can visit RoswellPark.org, that’s RoswellPark.org. You’re listening to Cancer Talk with Roswell Park Comprehensive Cancer Center. I’m Bill Klaproth. Thanks for listening.
Understanding Cytoreduction/Hyperthermic Intraperitoneal Chemotherapy (CS/HIPEC)
Bill Klaproth (Host): Recent advances in cancer treatments such as Cytoreduction Hyperthermic Intraperitoneal Chemotherapy, or Cytoreduction and HIPEC, has proven to be an effective treatment option for certain late-stage gastrointestinal cancers. Here to help us learn more about Cytoreduction and HIPEC is Dr. Valerie Francescutti, Assistant Professor of Oncology, Department of Surgical Oncology at Roswell Park Comprehensive Cancer Center. Dr. Francescutti, thank you so much for your time. What is Cytoreduction and HIPEC?
Dr. Valerie Francescutti (Guest): Well, it’s a combined surgical procedure where initially, as the first portion of the procedure, an abdominal tumor or tumor nodules are removed. Once all or near all of the visible tumor has been removed by the surgeon, we administer warmed chemotherapy into the abdominal cavity while the patient is still under an anesthetic and the rationale for this chemotherapy is the microscopic tumor cells that may remain that cannot be removed by the surgical portion of the procedure. Those two combined portions of the procedure are done at one setting at one time, and the benefit really is that the chemotherapy that’s provided into the abdominal cavity after the cytoreduction is given directly to where the problem is, which is in the abdominal cavity. We can provide it both at a higher concentration than we would be able to by providing it intravenously like standard chemotherapies are given, and also, the patient absorbs less of it, so the toxicities from that higher dose is less.
Bill: So, how does this work? Is that because of the heat component?
Dr. Francescutti: Several different things. There’s heat, there’s perfusion pressures, and also, the actual character of the chemotherapy drug itself being sensitive to the particular types of tumors that it treats. One of the more common types of chemotherapy that we use in this procedure would be Mitomycin C. Other types of chemotherapy include Oxaliplatin, which is another common chemotherapy drug that’s used. Both of those are probably the two most common ones. At Roswell, we tend to use the Mitomycin C most frequently. It’s the best studied and has had very good response rates.
Bill: And what are the advantages of the HIPEC procedure?
Dr. Francescutti: In terms of being able to remove all of the visible tumors at the time of the surgery, we can specifically deal with everything that is there that could, in the future, let’s say, cause a bowel obstruction. We can also reduce the amount that’s left in the abdominal cavity of any tumor to a very small amount where the chemotherapy that’s administered after the surgical part of the procedure can actually deal with it, and we know that there is definitely tissue penetration of the chemotherapy that’s given into the abdominal cavity to manage it.
The other part of that which is very important from a patient quality of life perspective is many of these patients, in particular, ones that have colorectal cancers or appendix adenocarcinoma type cancers do need to have some IV or standard chemotherapy treatments, and this procedure often times can follow that treatment. Often times, if the tumor in the abdominal cavity can be dealt with completely – completely removed, then we can actually get patients off of systemic chemotherapy where they can have a break from needing to have systemic chemotherapy continuously. It’s a nice way to consolidate treatment and be off of treatments and onto more of a surveillance strategy for a period.
Bill: Right, so very important advancements. Which patients are good candidates for the HIPEC procedure?
Dr. Francescutti: First, I’ll describe the types of patients that would be good candidates. First, it’s really important to select a patient that overall, is fairly healthy, has either fewer or well-controlled comorbid conditions. Patients that have heart issues if they’re well-controlled, blood pressure well-controlled, diabetes well-controlled, and can also be able to tolerate a fairly lengthy anesthetic as part of the surgery and the associated recovery required from this procedure. That would be how I would define a good patient for the procedure.
There are also tumor factors, so the type of tumor that a patient has. The most common types of tumors that we treat with this procedure would be those of the GI tract, as I had described -- usually, colorectal cancer, appendix cancer, and the appendix tumors can come in more of a higher-grade adenocarcinoma or a lower grade type of neoplasm. Also, some of the gynecological cancers such as ovarian cancer, and then lastly, the less common types of tumors that start directly from the cells of the lining of the abdominal cavity. Those tumors are peritoneal mesothelioma or primary peritoneal cancers. Those are usually the best-treated tumors with this approach.
The important parts about the patients’ extent of disease is really something that we carefully consider both on imaging and prior operations. What’s important is to have a patient who has a tumor that’s confined to the abdominal cavity, so does not have any evidence of spread outside of the abdominal cavity – say, for example, no lung metastases, or lymph nodes in the chest, or what have you -- that are concerning for spread. Now, if the patient has had spread to a solid organ – an example of that would be liver metastasis – the hope there would either be that it is a fairly small metastasis – it’s fairly easily managed with a lower-risk surgery, or it potentially has already been managed by a surgery prior to the HIPEC procedure.
When we look at the amount of peritoneal nodules or spread in the abdominal cavity, the lower amount and size of these nodules the better, and certainly, that they are all resectable – that we’re able to remove all of it or near all of it to be able to make sure that the remaining tumor is going to be sensitive to the HIPEC part of the procedure.
And then the last thing is I think I had mentioned is that a patient has actually derived some benefit from other treatments such as the IV chemotherapy. To see a patient who has had some IV systemic chemotherapy and has had a good response, or at least a stable looking CT scan over the period of time that they’ve received the treatments is always something that describes a good candidate for this procedure.
Bill: And speaking of patient benefit, can you share with us patient experience before and after the procedure?
Dr. Francescutti: Well, I think it’s very difficult to describe sometimes because patients come from a variety of different settings. Some come after having been diagnosed with their tumors several years prior, and the peritoneal metastasis that they come with are part of a recurrence or the tumor having come back. Other patients, that’s how they originally present to their gastroenterologist or their internist with the tumor that had already spread. I think patients are coming from a variety of different settings, so it’s very difficult to get a handle on the experience itself. I think that it is a very complex surgical procedure to discuss and it really does involve a lot of preoperative preparation – physical therapy, nutrition. It does involve an in-hospital recovery period, which is usually anywhere from 7 to 14 days. And then also, the recovery at home, which, depending on the actual surgical procedure and what is done for the patient that can be 6 to 7 weeks or longer recovering at home.
From my personal experience with these patients, I think many of them are very overwhelmed with the amount of information that they get. I think we’re also not the first or the only physician to see that patient, so we are part of the team that will be managing them. We are spending a good amount of time getting to know the patients, getting to understand their choices, and also, hopefully, that they are having all the information and the education that they need to proceed with this surgery and that they’re committed to the recovery period and so forth. We're very attuned to the physical and emotional side-effects and then also, the more extended experience of the social, and financial, and spiritual effects that this very life-changing procedure can have on patients. We’re paying particular to that as it’s very life-changing often.
Bill: Speaking of hospital and recovery time, what is the long-term effectiveness of the HIPEC procedure?
Dr. Francescutti: I think that the best way to describe that would be looking at some of the studies in patients with colorectal cancer because those are the patients that had been studied the best. There’s at least one randomized-controlled trial that looked at patients that just had IV chemotherapy compared with the group that had the HIPEC procedure and then IV chemotherapy as well. In patients that just have IV chemotherapy – those are including the newer agents that are being used, targeted therapies, and fairly effective IV chemotherapy agents per the medical oncologists that see them. The five-year survival for this group of patients is about 10% -- maybe a little bit less than 10%. When we add in the HIPEC procedure -- that would be HIPEC plus the addition of the IV chemotherapy drugs that they may need to get before a procedure or after a procedure – that survival at five-years could increase up to 35%. That’s a big jump there – a big difference for these patients.
In addition to just the survival part of it, the chemotherapy provided into the abdominal cavity – the HIPEC portion – can also help to palliate some other symptoms such as fluid buildup in the abdominal cavity termed ascites. Symptomatic management of some of the symptoms that the patients are having can be helped with the HIPEC procedure as well.
Bill: Very good. Well, Dr. Francescutti, thank you so much for talking to us today about Cytoreduction and HIPEC. For more information, you can visit RoswellPark.org, that’s RoswellPark.org. You’re listening to Cancer Talk with Roswell Park Comprehensive Cancer Center. I’m Bill Klaproth. Thanks for listening.