16 June 2021 Author : Francisco Senra What is HIPEC and in which tumors can it be used? HIPEC is the administration of chemotherapy compounds in the peritoneal cavity, associated with peritoneal lavage and high temperature. The t umors most often treated with HIPEC originate from: Appendix; Colon or rectum; Stomach; Small bowel; Ovaries, tubes or peritoneum; Mesotheliomas. However, in specific cases, other type of tumors may be with HIPEC. The association of chemotherapy, peritoneal lavage, and high temperature of HIPEC has a synergistic effect in the treatment of microscopic peritoneal oncological disease and complements the cytoreduction surgery, that is, the surgery to remove the visible peritoneal disease (macroscopic). Peritoneum, peritoneal carcinomatosis and mesothelioma The peritoneum is a membrane that lines the abdominal cavity and abdominal organs internally. Malignant tumors of the peritoneum can be: Peritoneal carcinomatosis or peritoneal metastases (the most frequent form of presentation), considered a secondary tumor, because it originates in other organs and then develops in the peritoneum; Mesothelioma , which is a primary tumor because it originates in the peritoneum itself. Most abdominal tumors can, along its evolution, release cells to the peritoneum, giving rise to peritoneal carcinomatosis. Peritoneal carcinomatosis is considered a terminal stage of cancer , has a poor prognosis and a life expectancy usually less than 1 year. This reduced life expectancy is associated with: The limited effectiveness of systemic chemotherapy (administered intravenously or orally) in the treatment of peritoneal carcinomatosis; The common development of intestinal occlusion in patients with peritoneal carcinomatosis, interfering with adequate nutrition; The limitations of surgery, as surgical removal of the disease is often not possible. Even when it is feasible, the persistence of tumor cells, which cannot be identified by the surgeon during surgery, is related to the recurrence of peritoneal carcinomatosis in a few months. What tumors can be treated with HIPEC? Hyperthermic intraperitoneal chemotherapy is a treatment with curative intent . It is indicated, mainly, in patients with totally resectable peritoneal carcinomatosis and without other disease (extraperitoneal). However, it can also be indicated if there is an extraperitoneal disease that can be removed in the same or in another surgery, performed before or after the HIPEC surgery, with the same curative intention. HIPEC is also indicated for the treatment of peritoneal disease in which there is production and accumulation of a large amount of fluid (ascites) that must be removed frequently. In this case, the objective is to control the production of ascitic fluid and decrease or eliminate the need for repeated punctures to remove it, thus improving the quality of life. Some studies suggest benefits of using HIPEC as a complementary treatment in the initial surgery of tumors with great potential for developing peritoneal carcinomatosis, as is the case with gastric carcinomas. In fact, it is known that after gastrectomy (removal of the stomach) for non-initial gastric tumors, there is a significant risk that patients will develop metastasis (disease outside the stomach), such as peritoneal carcinomatosis, in the first years after surgery. This is the justification for administering systemic chemotherapy prior to stomach removal surgery. Thus, there are several studies that suggest the benefit of using HIPEC in addition to gastrectomy of the initial tumor. However, this indication is still debated. How is HIPEC done? Current imaging tests - computed tomography (CT), magnetic resonance and positron emission tomography (PET) - have limitations in the identification and assessment of the extent of peritoneal carcinomatosis. The ability of these tests to detect peritoneal carcinomatosis nodules smaller than 1 cm is estimated to be 10%-30%. Thus, the most reliable way to assess peritoneal carcinomatosis is surgical evaluation (abdominal exploration). HIPEC is performed during surgery . The initial phase of a patient surgery proposed for cytoreduction and HIPEC is abdominal exploration; If the peritoneal disease is considered resectable (possible of being surgically removed), the surgery continues, with the removal of all visible disease; After this phase, the infusion of serum at the desired high temperature is started; When homogeneity and temperature stability are guaranteed throughout the peritoneal cavity, chemotherapy is added. The chemotherapy infusion time varies according to the drug used, between 30 and 90 minutes; Once the chemotherapy infusion is finished, the surgery is completed. Most often, patients will pass 1-3 days in intermediate or intensive care and are discharged after 8-12 days after surgery. Effectiveness of HIPEC Several factors contribute to the effectiveness of HIPEC. The tumor As with any chemotherapy treatment, the effectiveness of HIPEC depends on the sensitivity of the tumor to the drugs used. The surgical team It is the most important human factor for the successful treatment of peritoneal carcinomatosis. An experienced surgical team dedicated to the treatment of peritoneal carcinomatosis allows to optimize several essential steps: Selection of patients who can benefit from surgery; Preparation / optimization of patients for surgery; Extensive, thorough and exhaustive search for any nodule of carcinomatosis in the peritoneal cavity; Technical capacity to remove all peritoneal disease, limiting complications; Ensuring uniform distribution of chemotherapy and hyperthermia throughout the peritoneal cavity. The administration of chemotherapy For controlled administration of chemotherapy and hyperthermia in the peritoneal cavity, adequate monitoring equipment and systems are required, as well as the specific technical knowledge of a dedicated perfusionist. A multidisciplinary medical team After surgery with HIPEC, patients need continuous and attentive monitoring to correct imbalances and prevent complications. In this surgery, in addition to all the care already needed in a large and prolonged abdominal surgery, there are also the changes resulting from the use of chemotherapy and high temperatures. Close collaboration between the surgeon and intensive care team is essential in the recovery of the patient and in the prevention of complications. HIPEC debulking surgery may be the only treatment for some patients. However, the combination of systemic chemotherapy is usually necessary. A correct articulation between the medical oncologist and the surgeon allows to select the best systemic chemotherapy and the best time to do it, which can be before, after, or even before and after the surgical procedure. Meet the general surgery team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
