HIPEC is essential, but its not sufficient in management of peritoneal surface malignancy : Dr Paul H Sugarbaker

Shahid Akhter, editor, ETHealthworld spoke to Dr Paul H Sugarbaker, Director Peritoneal Surface Malignancy program and Surgeon at MedStar Washington Hospital Centre, US to know more about the management of peritoneal surface malignancy in the light of current evidence.

Surgical Treatment Evolution

We are just interested in this particular meeting in discussing peritoneal surface malignancy. There are some drugs that if we put them directly into the peritoneal space we will get a much greater response to that drug right within the region that the drug has been administered as compared to its effect throughout the entire body. Also, the toxicity will be reduced. So that was Bob Dedricks' contribution and then there was a fellow who found out that you could actually control these peritoneal metastases in rats with heat. It was an experimental model.

And there was another fellow by the name of John Sprat who combined the Inter - Peritoneal Chemotherapy with heat and came up with what we now call 'Hyperthermic Inter - Peritoneal Chemotherapy'. And we have been working on that problem now for the last 40 years. How can we use surgery and then augment the surgery with Hyperthermic Inter - Peritoneal Chemotherapy. It is quite interesting that when these first reports came out no one in the US or Europe paid any attention to them but the Japanese latched on to it and did a lot of interesting experiments then it returned to France and the US and here we are now some 40 years later studying what was just a very small project but it is now a huge project.

Cyto-Reduction Surgery & HIPEC

?My interest in patient selection is with radiologic studies, you know like a CT scan, computerized tomography and what we have done is quantitate. You know when you first study something, you just describe it as a phenomenon and then when you really begin to study it, you quantitate it. So, we are quantitating the CT scans in patients with Peritoneal Surface Malignancy in order to make an accurate assessment as to how long they are going to survive and it has been quite successful. It's not something that has been done before, the radiologists they just usually describe things. "Okay, there is cancer here, there is cancer there, there is dysfunction here."

Now, what we have done is that we took a specific finding on CT and relate it to the patient's survival. We call it the concerning radiologic features.

Cyto-Reduction Planning

The planning depends on the radiologic studies, it depends on a review of histopathology and the location of the disease. But, we plan to perform first what we call peritonectomy procedures. So the cancer sticks onto the side of the peritoneum and then it sets up vasculature and as soon as the cancer gets blood supply it will start to grow and the only way to get rid of it is to strip away the peritoneum. It's performing inside the body what would it be like to take off the skin. We are basically skinning the inside of the abdomen and pelvis. So that is how we start. We also have to sometimes resect the portion of the bowel. Large bowel, small bowel, pieces of the stomach, appendix, uterus and ovaries. So, we plan a various number of resections and then after we succeed in that we flood the abdomen with chemotherapy solution and then after that the patients would go on to receive (for the most part) stomach treatments and we will hope that whereas all these people in the past succumb that now atleast a goodly percentage of them will survive long term.

Rare Peritoneal Tumours - Your Experience

Rare Peritoneal Tumours is a real tragedy that people who have rare cancers can't find a good treatment. And the internet has been a help but there are a huge number of patients who have rare tumors, who don't get treated because the doctors locally don't know what to do. So, we have put together a registry of rare malignancies and we have come up with a strategy for treating these rare tumors. So, first of all the rare tumors have to have a low grade of malignancy. If you take on a tumor that is going to spread all over the body, our treatments are not going to work. So, if we have a low grade of malignancy it has to be completely removed with the peritonectomy(s) and visceral resection(s) that is resection of organs and then we have to choose the proper and the optimal chemotherapy because most tumors respond well to one drug and then other tumors respond well to other drugs. So we have to come up with a treatment, regiment of chemotherapy that is appropriate for that particular rare tumors. Those treatments are in the process of evolution but we are able to cure a lot of patients who previously had no treatments at all.

Managing Colorectal PM in the light of current evidence

Now you have really hit on the source part because we did this trial, the french did a trial and they asked the question how much benefit is there to using HIPEC after you do cyto-reductive surgery for colon cancer. The answer came up with is that only a very small number of patients profit from this inter-Peritoneal oxalic platinum chemotherapy. It set the treatment regiments and plans for colon cancer peritoneal metastasis way back because what we have been doing for years and years its unsuccessful. So, in light of the failure of prodigy VII, to give the positive results we are having to go back to the drawing board and design new cancer chemotherapy treatments, those that are infused into the peritoneal space for patients who have cyto-reductions for colon cancer.

We thought we were doing a good job for 20 years and it turns out that there was a very benefit from HIPEC. So the real question is why does the HIPEC, the chemotherapy with heat, used in the operating room. Why is it only effective in say colorectal cancer on 20 per cent. Why don't we have it for 50 per cent. So, most probably what we will start to do is not to just use one HIPEC or one P-PEC or one NI-PEC. We are going to use multiple regional treatments, multiple cycles. We call it cycle as one treatment plan may take one day, may take five days, but one cycle of chemotherapy say once a month for 6 months and if it is working maybe for a full year. So in our peritoneal mesothelioma patients we do the cyto-reduction using HIPEC and we put a port in and the chemotherapy goes directly into the peritoneal space for 6 months. That I think will be the future of the management of peritoneal surface malignancy. Not that HIPEC is not good, HIPEC is essential, but its not sufficient and we want now to add treatments on top of the CRS and HIPEC.