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Cytoreductive Surgery and Intraperitoneal Chemotherapy

Oncology Associates provides Surgical Oncology Services for
Sharp Healthcare and Scripps Hospital systems.

Cytoreduction HIPEC and Intraperitoneal Chemotherapy Programs

Our advanced services include specialty treatment programs for cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (cancers that have spread within the abdominal cavity). These tumors include cancers originating from the appendix, stomach, colon, rectum, ovary, primary peritoneal, sarcoma, and mesothelioma. Tumor cells originated from these cancers arising in the abdomen can spread by three different routes. These are: Blood vessel spread, lymphatic spread, and spread to the peritoneal lining. If the tumor has spread to the peritoneum a specialized technique called cytoreductive surgery is utilized to remove these tumors attached to the peritoneal surfaces. Some tumors involving the peritoneal lining are less aggressive and do not cause immediate life threatening situations. Patient’s can have long term survival, but with time, these eventually have a fatal outcome with cancer progression within the abdomen. More aggressive tumors need to be treated before they become too extensive because eventually they will involve vital structures that cannot be removed. The best chance of removing the entire tumor depends on many factors: extent of tumor, location and histologic type.

Pseudomyxoma Perotoni Syndrome (PMP)

This term means “false mucous tumor of the peritoneum.”  It is usually applied to tumor that is slow growing with extensive mucous production within the abdomen.  These tumors usually arise from a mucous adenoma of the appendix or ovary.  Enormous amounts of mucous can fill the abdomen cavity without having many symptoms except a “big belly”.   The large accumulation of mucous is sometimes called “jelly belly”.   Pathologically these tumor are called DPAM or disseminated peritoneal adenomucinosis.  This tumor is not considered malignant since it rarely spreads via the lymph system or blood stream.  Despite being benign, it will eventually almost always result in death. These tumors are best treated with cytoreductive surgery and HIPEC since they rarely respond to chemotherapy.

Peritoneal Carcinomatosis-Cytoreductive Surgery-HIPEC

Some tumors arising from the gastrointestinal tract and gynecological organs have their primary route of spread  within the abdominal cavity alone.  The primary tumor or site of origin, if left untreated, will eventually grow outside the organ involved, thus allowing the tumor to shed tumor cells into the abdominal fluid which can then lead to spread throughout the abdominal or peritoneal cavity.  These cells can then implant on the peritoneal surfaces of the diaphragm, liver, spleen, omentum, pelvis, or on the surfaces of the bowel and bowel mesentery. Eventually these cells will grow and become visible growths on the peritoneal surfaces and organs. When it does this, it is called peritoneal carcinomatosis. The procedure to remove tumors that have spread throughout the abdomen is called “cytoreductive surgery.”

In some cases where there is no visible spread within the abdomen at the time of primary tumor removal, tumor cells are spread from handling the tumor in the course of removing it.  These cells will then eventually implant themselves on the peritoneal surfaces.  A similar phenomenon occurs during cytoreductive surgery. In the course of surgical tumor removal, microscopic tumor cells are shed or left on bowel and peritoneal surfaces.

Recently a new approach to eradicate these invisible cells that are shed or left behind during these procedures has evolved. The technique is to place solutions containing chemotherapy immediately into the abdomen at the same time of the surgery. Administering intraperitoneal chemotherapy immediately at the time of surgery avoids having the microscopic tumor cells eventually grow and become trapped in adhesions or fibrin surface scar which protects them from intraperitoneal chemotherapy administered at a later time. 

The technique of placing catheters into the abdominal cavity and instilling heated chemotherapy solutions is called HIPEC.

Hyperthermic Intermediate Intraperitoneal Chemotherapy (HIPEC)

Over the past 30 years, we have been treating tumors that have spread to the peritoneal cavity with a surgical technique called cytoreductive surgery. These procedures remove all the visible tumors leaving only microscopic residual disease or tiny deposits on the bowel surfaces and within the peritoneal fluid. Immediately after the cytoreductive procedures are completed, chemotherapy is delivered directly into the abdominal cavity. The chemotherapy solution delivered is heated to 109° F. Heat is known to have a greater affect of killing tumor cells than normal cells. In addition, heat causes the tumor cell membrane to become more permeable to the chemotherapy drugs delivered and thus thrust the drug into the cell resulting in cell death. The chemotherapy solution is delivered continuously for 60 to 90 minutes.

Tumors Treated

  • Pseudomyxoma peritonei-PMP for appendiceal and ovarian cancers.
  • Adenocarcinoma-appendix, colon, rectum, stomach, ovary, uterus, primary peritoneal. 
  • Sarcoma-soft tissue, GIST tumors, carcinoid, uterine. 
  • Mesothelioma.

Debulking or Cytoreduction

The technique to remove the gross tumors on the peritoneum is called cytoreductive surgery. These are very complex procedures which include stripping the peritoneum (lining the abdomen) involved by the tumor. There are nine (9) peritoneal compartments within the abdomen. Some of these peritoneal areas involve portions of the intestine which may have to be removed as well.

We have been performing cytoreductive surgeries for over 30 years. We are the first center to perform this procedure in the Western United States. We have an experienced team dedicated to the cytoreductive surgery program at Sharp Memorial Stephen Birch Hospital. The team includes nurses, medical oncologists, in-house 24 hour critical care specialists, pulmonologists, anesthesiologists, endocrinologists, and infectious disease physicians, all of whom have been part of our team and are very familiar with the care needed to get you through your hospitalization. We have one of the best invasive radiology departments in the country whose physicians are experienced in treating postoperative complications if they should occur.

These procedures are difficult and time consuming. The time of each operation depends on the number of peritoneal surfaces that are involved and the volume of tumor within the abdomen. The average length of these procedures is 8-10 hours, more extensive tumors, can take up to 20 hours.

For more aggressive tumors, systemic (intravenous) chemotherapy is given before the surgery to try to reduce the amount of tumor before performing the cytoreductive surgery. 

Because of the magnitude of these surgeries, the postoperative complication rate is high. This will depend on the extent of surgery, time of surgery and blood loss.

Location and Preparation

The surgery is performed at Sharp Memorial Stephen Birch Hospital located in San Diego, California. The new hospital was completed in January 2009. The hospital has all private rooms including those in the surgical, medical, and intensive care areas. One member of your family can stay in the room with you. Nearby discounted hotel rooms are available for other family members.

You can expect a stay in the ICU for one to three days after your surgery depending on its length and magnitude. You will be then transferred to the oncology floor. Both in the ICU and on the oncology floor, you will be cared for by nurses who have extensive experience in caring for those complex cases. 

There are also excellent support services if needed including social services, pastoral care, rehabilitation, home nursing, and infusion therapy. 

Under our care, you and your family become part of our family. You receive personalized service from Dr. Barone, other members of his team, and the hospital staff.

Information Needed

Please send us the following information:

  • Insurance card
  • All operative reports
  • All pathology reports
  • Copies of all radiology reports and discs of all your studies
  • All recent laboratory reports
  • Consultation reports and progress notes from your physicians
  • Let us know if you have any medical conditions such as COPD, diabetes, or heart disease.
  • Give us the names, addresses, and phone numbers of all your physicians who have been caring for you

MRI For Peritoneal Surface Malignancies

Our institution has extensively studied the role of MRI in determining the extent of peritoneal disease for peritoneal surface tumors. We have found that CT scans are inaccurate in diagnosing the extent of peritoneal disease in addition to exposing you to unnecessary radiation.  We would want you to have an MRI study at our institution. This study will accurately determine the extent of your disease and the surgical procedures needed to remove it.

Peritoneal MR Imaging and Sharp and Children’s MRI Center
Russell N. Low, MD

MR imaging can non-invasively and accurately show small peritoneal tumors that are invisible on other imaging tests such as CT or PET. While CT and PET often miss small but important peritoneal tumors, MRI routinely shows small tumors only a few millimeters in size. MRI achieves this remarkable accuracy without using any radiation making it a safer, more accurate, and less expensive alternative to CT.

Our longstanding interest in using MRI to evaluate patients with peritoneal tumor stems from a close collaboration between radiology and surgical oncology. This exchange of knowledge and ideas between Dr. Russell Low and Dr. Robert Barone has allowed us to devise and perfect imaging techniques for peritoneal disease that are truly unique and trend setting.

Our MRI approach to peritoneal tumor involves using gadolinium-enhanced imaging to show enhancing peritoneal tumors. We also rely on diffusion weighted MR imaging (DWI) as these tumor often light-up on diffusion imaging. Patient preparation involves distending the small bowel and colon with water soluble contrast for optimal imaging.

The clinical uses for peritoneal MRI include essentially any patient with abdominal malignancy, including ovarian cancer, colon cancer, pancreatic cancer, gastric cancer, primary peritoneal tumor, and appendiceal cancer. The ability of MRI to show subtle peritoneal tumors can provide your oncologist or surgeon with vital information that can help lead to the correct diagnosis and optimal management.

For example, in patients with appendiceal cancer MR imaging for preoperative assessment prior to CRS and HIPEC may improve patient selection and preoperative planning. We have found that MRI can accurately predict the surgical PCI score and can be used to stratify patients into those with small volume (PCI score <10), moderate volume (PCI score 11-20), and large volume (PCI score >20) intraperitoneal tumor. Combined with the histological grade of the tumor the MRI PCI score can be used to select patients who are more likely to achieve a complete surgical cytoreduction with less morbidity. Non invasive DPAM tumors can be successfully surgically cytoreduced even with large volume tumor.

The early detection of recurrent tumor on serial laboratory tests and imaging studies plays a critical role in identifying patients who should be considered for repeat CRS and HIPEC. While CT scanning is commonly used to image patients with appendiceal cancer its limitations for showing small peritoneal tumors is well documented. MR imaging has inherently superior contrast which allows it to depict small peritoneal tumors more effectively. At our institution we have been using MRI in patients with appendiceal cancer for preoperative staging and for surveillance following CRS and HIPEC.

Imaging studies can play an important role in monitoring patients following CRS and HIPEC. However, the limitations of CT in patients with peritoneal carcinomatosis are well understood. Koh et al confirmed that CT significantly underestimated intraoperative PCI detecting only 11% of peritoneal tumors <0.5 cm compared to 95% of tumors larger than 5 cm. In a multi-institutional study Esquivel et al found that the preoperative CT PCI score underestimated the extent of carcinomatosis in 33% of patients. The poor sensitivity of CT for detecting small peritoneal tumors limits its accuracy in determining a patient’s preoperative PCI score and in detecting recurrence following CRS and HIPEC. Concerns about the cumulative radiation doses from repeat CT scans also favor the use of MRI for surveillance. The amount of radiation from a single CT scan is equivalent to the radiation exposure from hundreds of chest xrays!

We believe that dedicated Peritoneal MRI should be used for all patients with known or suspected peritoneal tumors. The accuracy of MRI for showing tumors of the peritoneum is superior to CT and PET and makes it the examination of choice.

References:

1.      Low RN, Barone RM.  Combined Diffusion-Weighted and Gadolinium-Enhanced MR Imaging Can Accurately Predict the Peritoneal Cancer Index (PCI) Preoperatively in Patients Being Considered for Cytoreductive Surgical Procedures. Ann. Surg Oncol 2012;19:1394–1401.
2. Low RN, Barone RM, Gurney JM. Mucinous appendiceal neoplasms: preoperative MR staging and classification compared with surgical and histopathologic findings. Am. J. Roentgenol 2008;190:656–665. 
3. Low RN, Sebrechts CP, Barone RM, Muller W. Diffusion-Weighted MRI of Peritoneal Tumors: Comparison with Conventional MRI and Surgical and Histopathologic Findings--A Feasibility Study. Am. J. Roentgenol 2009;193:461–470.
4.   Koh JL, Tan TD, Glenn D, Morris DL. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol. 2009;16:327–333.
5. Esquivel J, Chua TC, Stojadinovic A, Melero JT, Levine EA, Gutman M, Howard R, Piso P, Nissan A, Gomez-Portilla A, Gonzalez-Bayon L, Gonzalez-Moreno S, Shen P, Stewart JH, Sugarbaker PH, Barone RM, Hoefer R, Morris DL, Sardi A, Sticca RP. Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study. J Surg Oncol. 2010;102:565–570.

Follow Up

When you're ready to be discharged from the hospital, if you have come from a distance more than 200 miles away, we would like you to stay in the vicinity for a week to 10 days.  This to make sure that you are strong enough to care for yourself and have no complications that may be developing. 

You will also need a physician in your locale to follow you with us in the event that there are delayed complications. 

We will see you in a month to six weeks after your discharge. You will need blood tumor markers every three months and would like you to return to our office every six months for physical exam and MRI.

If you would like further information or would like to speak to one of our patients who have received care for HIPEC at our institution, please contact us.

Contact:
Surgical Oncology Associates
Robert M. Barone, M.D. FACS
3075 Health Center Dr. Suite 102
San Diego, CA 92123

Phone – 858-637-7827
Fax - 858-637-7842 or 858-637-7887
Email – baronemd@aol.com

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