At the point where the desired response from the cancer treatment cannot be obtained, the “intra-abdominal warm chemotherapy-HIPEC” method, which is a method that increases the quality of life and comfort of the patient, provides significant advantages.
What is HIPEC?
HIPEC; Hyperthermic intra-abdominal chemotherapy (Intra-abdominal warm chemotherapy) is a form of treatment called “Hyperthermic Intraperitoneal Chemotherapy”, which has been frequently mentioned in the treatment of cancer in recent years. Today, many different methods are used in cancer treatment and significant successes are achieved. The application of intra-abdominal warm chemotherapy, called HIPEC, is one of the most important steps taken in this field in terms of both prolonging the patient’s life expectancy and increasing the quality of life.
In which diseases is it used?
In some cancers originating from the intra-abdominal organs, systemic chemotherapy given before (neoadjuvant treatment) or after (adjuvant treatment) or both before and after surgical treatment may not give the expected response. In this case, when the desired response to the applied treatments is not achieved, the disease progresses gradually and eventually the life of the patient may be endangered.
In patients with peritoneal involvement in the advanced stage of cancer, fluid (ascites) begins to accumulate in the abdomen. This fluid may cause the patient’s abdomen to swell gradually, causing breathing and circulation problems with the pressure and tension it creates. Sometimes it becomes so common that it even prevents the patient from lying down. In addition, it causes the spread of cancer cells to other areas in the abdomen. Although it is possible to drain the fluid through the cannula for the patient’s relief, as the pathology continues, there will be fluid collection again.
A patient group with advanced cancer has left all treatment options behind, and in this case, HIPEC treatment, which will prolong the patient’s life span and provide life comfort, comes to the fore. With this procedure, cancers of the peritoneum themselves, Successful results are obtained in appendiceal cancer and ovarian cancer in women. In addition to these, it has also started to be applied in cancers of the large intestine, stomach and recently pancreas.
While performing such treatments, some components should not be ignored. It makes sense when all phases of treatment are carried out together. For example, in gastric cancer patients, “Neoadjuvant intraperitoneal systemic chemotherapy -NIPS” is started, followed by gastric resection, cytoreductive surgery + peritonectomy + HIPEC, and then the treatment is completed with systemic chemotherapy. HIPEC application alone can be applied to patients with ascites who are not suitable for cytoreductive surgery due to their general condition and disease, only “palliation”, that is, to reduce the complaints to some extent. This application, which does not affect the survival time, is performed laparoscopically through catheters placed in the abdomen.
Treatment option in advanced intra-abdominal cancer: HIPEC
The following is aimed with the application of intra-abdominal chemotherapy: The intra-abdominal organs are covered with the peritoneum, which is called the peritoneum. This structure covers both the surface of the intra-abdominal organs and the inner surface of the abdominal wall. Thus, small amounts of chemotherapeutic agents administered intra-abdominal affect both the cancer cells in the target organ and other organs and areas where it has spread, and destroy the cancer cells.
How is HIPEC treatment applied?
Cancer; It can spread by spilling blood, lymph nodes and abdominal cavity. Therefore, in intra-abdominal cancers, the tumor may spread to the peritoneum in the advanced stage of the disease. In this situation, which occurs in the last stage of cancer, the drugs administered to the patient may not reach the peritoneum at the desired level and the treatment will be insufficient. However, the peritoneum, which is covered with a dense tumor, should be evaluated as an organ philosophically, and the organs or organs involved together with the peritoneum should be cleaned and the inside of the abdomen should be made as tumor-free as possible microscopically.
This procedure is called “cytoreductive surgery + peritonectomy”. Following these procedures, tumor-destroying drugs with a temperature of 42-43 degrees are given into the abdomen with a special apparatus. The intra-abdominal washing process takes 60 to 90 minutes. is completed between
The peritoneum and other organs (ovary, colon, stomach, etc.) that are involved with the cancerous organ in the entire abdomen are removed, and macroscopic tumor removal and complete or near-complete cytoreduction are performed. During these procedures, it may be necessary to temporarily insert the small or large intestine into the abdominal wall. After the treatment is finished, the intestine is taken back inside. Without these processes, the HIPEC application alone will not make much sense.
On the other hand, performing only cytoreductive surgery + peritonectomy alone does not make much sense. These two components should complement each other. Cytoreductive surgery + peritonectomy + HIPEC should be followed by systemic chemotherapy. HIPEC application is performed after intra-abdominal tumor removal. After tumor removal, a total of four drains, one for each, are placed in the lower and upper quadrants of the abdomen.
The ends of the drains outside the abdomen are mounted on the HIPEC device (which is a special device that heats the chemotherapy fluid). Two temperature probes are placed, one on the lower side and one on the upper part of the abdomen, to monitor the temperature level. Thus, as long as chemotherapy is given, the temperature is kept at the desired constant level and monitored. It is desired that the given chemotherapy fluid be 42-43 degrees centigrade. The amount of chemotherapy fluid given is approximately 3 liters. Washing time with chemotherapy fluid is around 60-90 minutes. At the end of the procedure, the fluid in the abdomen is withdrawn and the procedure is terminated.
Frequently asked questions about HIPEC treatment
Why are chemotherapy drugs given by heating?
• By heating the anticancer drugs into the abdomen, it facilitates the penetration of the drug into the tissue and increases the cancer cell killing effect of the selected chemotherapy agent.
• The heat itself has an anti-tumor effect and the heat contributes to the equal distribution of the drug to all surfaces in the abdomen.
• During the HIPEC process, tumor cells are mechanically cleared from the surfaces of the small intestine and through the clot-fibrin layers.
In what situations is it not applicable?
HIPEC application is not performed in cases that originate from intra-abdominal organs but have metastasized to extra-abdominal organs and tissues, that is, in cases where there are involvements outside the abdomen (brain, bones, lung metastases…). If there are three or less metastatic foci in the liver, they can be removed and HIPEC can be applied. However, there is no indication for HIPEC in cases of extensive liver metastases. The important organ for a process is the small intestine. Since the small intestines are the organs of nutrient absorption in the digestive system, large intestinal resections are incompatible with life. For this reason, it does not make much sense to apply HIPEC in patients with extensive small bowel involvement.
What is the effect on life expectancy and quality?
The majority of these patients are patients whose life expectancy is limited to months due to advanced stage cancer. This important detail should not be ignored, it should be taken into account that the disease cannot be completely treated and eliminated, but life comfort and life expectancy can be extended. HIPEC application has different long-term results in different intra-abdominal organ cancers. In these advanced cases, the 5-year survival rate in pseudomyxoma peritonei, which is the own cancer of the peritoneum, is around 66% to 97%.
Of the intra-abdominal organs, ovarian cancers are the cancers with the best benefit and the 5-year survival is around 50%. The 5-year survival rate in colon cancers is around 30% in suitable cases. This situation is slightly different in stomach cancers, and it progresses worse than ovarian and colon cancers. While the life expectancy of patients with advanced gastric cancer with peritoneal metastasis is normally around 6 months, talking about the 5-year survival of a certain percentage of patients is quite promising regarding the success of the treatment applied.
Does the application have risks?
The risk rate of cytoreductive surgery and HIPEC surgery, which is a complex treatment, is higher than other elective standard operations. However, good results are obtained in patients who are well prepared before the operation and are well observed and followed up during the operation. Bleeding during surgery, embolism (such as lung, brain); Complications such as bone marrow failure, kidney failure, anastomosis separation and wound infection may be encountered due to chemotherapy.
Such complications can be minimized by being organized by experienced teams in experienced centers. Postoperative mortality, that is, the risk of losing the patient, is between 0 and 7% on average, although you can see it at different rates in the literature. In such advanced and severe cancer cases,
Who is it suitable for?
Patients with adequate general status assessment and scoring and no spread to extra-abdominal organs and tissues are suitable for cytoductive surgery+HIPEC.
What should be considered in the diet after HIPEC?
Sugar consumption should definitely be reduced as much as possible. Because the tumor cell feeds on sugar. Therefore, it is necessary to stay away from foods containing sugar. While the patient thinks that he is fed with sugary foods, he is actually feeding the tumor cell. Only soda can be drunk from acidic beverages. However, this depends on the area where the patient has surgery. Acidic drinks are not recommended for a patient who has had a total gastrectomy surgery. Patients outside this group can drink soda, excluding sugary acidic beverages. In addition, the diet after HIPEC progresses in the form of protein-based nutrition under the control of a dietitian.
Is systemic chemotherapy also applied to patients undergoing HIPEC?
Yes, HIPEC is not a stand-alone method. There is a chemotherapy process before it. HIPEC is applied when the tumor stops shrinking after a certain point in chemotherapy or when the tumor starts to progress and the side effects of systemic, that is, normal chemotherapy, increase. After these side effects subside, it is continued with systemic chemotherapy again. When the dose of drugs given to tumors that have spread in systemic chemotherapy is not sufficient, this dose cannot be increased.
Because increasing the dose may disrupt the patient’s vital functions. For this reason, systemic chemotherapy becomes more effective in this group of patients as the tumor mass is reduced or almost completely eliminated after HIPEC application to be applied together with cytoreductive surgery. Because the tumor area that chemotherapy drugs are struggling with becomes smaller.