Treating Cancer with Hyperthermic (or Heated) Intraperitoneal Chemotherapy (HIPEC)
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Treating Cancer with Hyperthermic (or Heated) Intraperitoneal Chemotherapy (HIPEC)
Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
Welcome again, everybody, to Butts & Guts, I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio.
We are always happy to have a recurring guest here, so I'm very pleased to welcome Dr. Michael Valente, who is a staff surgeon in the Department of Colorectal Surgery here at the Cleveland Clinic. Mike is also our program director for our Colorectal Fellowship, and Mike also leads what we're going to talk about today, and that's the patients with carcinomatosis and our cytoreductive surgery and HIPEC. Mike, welcome back to Butts & Guts.
Michael Valente: Thank you, Dr. Steele, it's my absolute pleasure to be back on the program.
Scott Steele: So Mike, let's start from a very broad level at first. Colorectal cancer in general, how big a problem is this?
Michael Valente: It's a big problem, Dr. Steele it's the third leading cause of cancer-related deaths in the United States of America.
Scott Steele: Yeah, so this is a big deal, and it's one of the things I know we've had other people on in terms of Butts & Guts just talking about the importance of screening, it's one of those things we can catch at an early phase. So Mike, you've got colon cancer, you've got rectal cancer, we're one long garden hose from our mouths all the way down to our bums, and this can occur. We'll talk a little bit about carcinomatosis today, but how does it spread? How does it get out of the box, and where does it go to?
Michael Valente: Good question. Colorectal cancer can spread in a couple of different ways. One of the most common ways is what we call lymphatic spread, which goes to the lymph nodes, that's classically the most common. It could also spread from the lymph nodes to the blood system, and then it could go to the liver or the lungs.
And then another way that colon cancer can spread is directly from the colon into the lining of the abdomen called the peritoneum, which is what we would consider someone with carcinomatosis or colon cancer that has spread to the lining of the inner layer of the abdominal cavity.
Scott Steele: Yeah, one of the analogies I've always heard is picture your belly like a trashcan, and the lining to that trashcan, if you put a trashcan liner in there it's the peritoneum, and you've got all your different organs in there. So we're really talking about cancer that is on the inner part of that trashcan liner in your peritoneum, in that abdominal cavity. And again, that's something that we're going to focus in on today.
So Mike, fancy word we then call that, we call it carcinomatosis, and again we talk about colorectal cancer, but really what we're talking about with a lot of these different cases is the fact that cancer cells from the GI track, including the appendix, which we'll get into a little bit later, can spread in that area. And so we talk a lot about chemotherapy, and we talk about giving people chemotherapy, but what is HIPEC, H-I-P-E-C, HIPEC, why is that different?
Michael Valente: HIPEC stands for Heated Intraperitoneal Chemotherapy. HIPEC is very different from what we normally consider chemotherapy. Normal chemotherapy, or systemic chemotherapy, is given intravenously through the IV into the bloodstream, it affects the entire body. Heated Intraperitoneal Chemotherapy is a bit different, it's actually delivered directly into the abdominal cavity at a heated temperature, about 105-108 degrees Fahrenheit, 41-42 degrees centigrade. And that chemotherapy bathes the inner lining of the abdominal cavity to directly contact any cancer cells that may be left behind, usually in conjunction with what we call cytoreductive surgery, and we'll get to that.
Scott Steele: So what's interesting about this whole process is the fact that we talk about a subset of patients that essentially are pretty unique in the fact that they are candidates for this disease. And so you mentioned a couple of topics there, let's kind of drill down on those. The first one is that cytoreductive surgery, what does that mean?
Michael Valente: When a patient has cancer cells that are embedded in the lining, in the peritoneal cavity on the peritoneum, cytoreductive surgery is the surgical procedure where the surgeon goes in and removes, or another term is debulks, all of the gross disease that we can see with the naked eye, that's a really important process.
And then after we debulk all the gross tumor that we can see, the chemotherapy will then potentially take care of all of the things that we can't see, the microscopic cancer cells, or even the smallest cells that may not be visible to the naked eye. And those two in conjunction have been shown to increase survival in certain types of cancers.
Scott Steele: So Mike, I want to make sure our listeners understand out there, we're not talking about liver surgery here.
Michael Valente: Generally speaking, no.
Scott Steele: Yeah, we're talking about taking those tumor cells that deposit themselves in that peritoneal lining. So I must ask you, how common of an occurrence is this, and is everybody a candidate that has tumor that's spread to their peritoneum, a candidate for this type of surgery?
Michael Valente: Not everyone's going to be a candidate for this operation, but I will say that there are lots of patients out there that may be a candidate, and this technique has been shown to hopefully decrease recurrence rates and increase survival. So, to answer the question, it's not for everyone, there's definitely a subset of patients that could benefit from this procedure.
Scott Steele: Yeah, I think some of our patients may be interested to learn that back in 2009 the Digestive Disease and Surgery Institute here at the Cleveland Clinic became one of the first centers in the U.S. to receive FDA approval for this form of chemotherapy in selected patients, and so we have a rich history of this right here. So Mike, a lot of different cancers can spread intraperitoneally, so are there some that have a better kind of way that we can treat with cytoreductive surgery and HIPEC than others?
Michael Valente: Sure, there's definitely a list of tumors that are out there. First and foremost, appendiceal cancers or appendiceal neoplasms, primary peritoneal cancers such as mesothelioma, a condition referred to as pseudomyxoma is also one that is very often used for this. Also colorectal cancer, as we mentioned, many ovarian cancers, and there are some patients with gastric cancers that can also receive this procedure.
Scott Steele: So some of the people out there that have been listening to Butts & Guts in the past may have heard this as we've talked about some of the various malignancies, but again, there are ones that have been used for in the past, and gastric has been one of the ones that has not had the greatest success, but appendiceal has been one that has been a little bit more.
Mike, when we look at the actual tumors themselves, you mentioned a term there that was called pseudomyxoma peritonei, that's another fancy word. What is this, and is that one of the better-acting players, or is that ... Because really it's the terminology that is sometimes so confusing. Patients will say to me, "I went online and I heard something about a low-grade mucinous neoplasm, I read something about this pseudomyxoma, and I read something about poorly differentiated adenocarcinoma," and the knowledge itself is overwhelming. Can you help kind of put their arms around each of these terms?
Michael Valente: Absolutely. And it's not just the patients who may have a hard time with the terminology, a lot of surgeons and medical professionals get a bit confused as well because there are so many different terms out there. Now, as we talked about pseudomyxoma peritonei, that's usually caused from an appendiceal lesion that may produce this mucin or mucus-like material. And that is actually one of the most common indications for cytoreductive surgery and HIPEC, and one of the most successful as well, with good longterm success. Sometimes the only treatment that may be needed for those conditions is cytoreductive surgery and HIPEC.
And really what that is, pseudomyxoma peritonei, is the appendix has now shed, or sometimes ruptured, and that mucin or that mucus jelly, as we call it, can embed or implant on the peritoneal lining of the abdominal cavity and other organs. And after those implant, then they make more mucous and more mucin. That in itself is not technically an invasive cancer, but it sure acts like one. Bowel obstructions, other disease processes that can occur. So we treat it like a malignancy, that's one of the most successful ways that we can treat those.
Scott Steele: So when you have these types of tumors, Mike, is the chemotherapy in and of itself something that can work if you just leave gross tumor behind?
Michael Valente: No, the goal is to get what we call a cytoreductive score of zero, meaning that we've removed all gross tissue that we could possibly see that's involved. And then the chemotherapy is used as an adjunct to kind of clean up anything that may be left behind in terms of micrometastatic disease or microscopic disease.
Scott Steele: So walk me through, I'm a patient out there that knows somebody that has carcinomatosis, or potentially was just recently diagnosed with this, and they want to come into your office. Walk me through what they can expect during that appointment, and then also tell me a little bit about how can you sort out the patients that are good candidates for this type of procedure versus those who aren't a candidate and would be better served by other means.
Michael Valente: Typically, the office visit would consist of me receiving all of their records beforehand, pathology records and any other operations they had, to understand what type of tumor they truly have, what the pathology is. And usually that requires ... Patients already had mostly CAT scans, or maybe PET scans you may have heard of, those usually are performed after they've been diagnosed.
I review all of those with our team, we have a multidisciplinary team, a cancer group that reviews these on a weekly basis, looks at the films, looks at the pathology and discusses each patient individually at our cancer conference. So I'll get that information. Based on their tumor type, and depending on what kind of treatment they may have had before meeting me, or if they are currently on some sort of systemic chemotherapy, we take all those factors into consideration, what kind of tumor they have, how much tumor there may be on CAT scans.
And the last thing you asked me is who can benefit from it or who can't undergo it. So we look at their personal and physical fitness and ability to undergo this type of operation. All of those things in conjunction, we put that together and make a plan for potentially an operation.
Scott Steele: So when they come into your office, do you have some kind of red flags that jump out that you say, "This isn't a good candidate to undergo this procedure"?
Michael Valente: The office visit at first is usually just a big discussion about what's going on, what we can potentially do, and if we are a candidate for surgery. Any red flags you mention, there are certain cancer types that are much more aggressive that generally speaking would require chemotherapy through the IV first, before we would think about or attempt an operation.
And those particular patients, if we do decide that an operation is best for them, very often we will do what we call a diagnostic laparoscopy where we put a small incision, put a camera in, and take a look around to see if we can indeed remove all the tumor deposits. Sometimes, about 10-15% of the time, we do that procedure and we cannot perform the operation because the tumor burden is just too great and we can't achieve a full reduction.
Scott Steele: So Mike, give us a look behind the curtain, tell us a little bit about what you do in the operating room.
Michael Valente: I think there's one thing I want to just tell all the audience members, is this is a big operation, but people do quite well with it. In the operating room, we make an incision, it's usually a large incision to gain access to the full abdominal cavity. This is after we put a camera in and decide that we can proceed. And then at that time we assess the entire abdominal cavity and see exactly how much disease there truly is, and if we can in our best minds remove everything. If we decide that it's probably not in the patient's best interest and we can't remove everything, we'll stop at that time, because no benefit will be gained.
During the procedure, depending on the tumor type, location, we'll do our cytoreductive surgery, which includes debulking, or stripping sometimes you may hear it, of the peritoneal lining in some instances. Sometimes other organs may need to be removed, such as the colon, small intestine sometimes, sometimes the spleen, and then usually those organs may or may not be reconstructed immediately. When the cytoreduction is completed, then we start doing the chemotherapy portion of the procedure.
Scott Steele: So Mike, just to clarify a little bit more, you were saying that sometimes we have to remove part of the bowel. Do we have to remove all of the bowel, or is it just sections of the bowel, can you live without your small bowel?
Michael Valente: Good question. To the last question, you cannot live without your small bowel, so one of the main reasons we may abort a procedure is if there's extensive small bowel or small intestinal disease process there, because we can't remove all of that small bowel. Now, the colon, other organs, we could routinely remove them without a problem.
Scott Steele: And then people that undergo this surgery, do they have to have a bag, otherwise known as a stoma or an ostomy?
Michael Valente: Yeah, great question, we get that question all the time. The short answer is maybe. If we are removing parts of the small intestine, not necessarily, but very often parts of the colorectum have to be removed and reconstructed. And very often when we give the chemotherapy, the bowels get quite angry, and they're inflamed and full of fluid and edema we call it, and very often we'll make a connection, but provide a temporary ostomy or bag for several months, just to let those bowels heal so they could get on their way without having a complication.
Scott Steele: But they don't necessarily have to have a bag.
Michael Valente: No, they do not.
Scott Steele: And then complications that can occur with this type of surgery, how long can the patients expect to be in the hospital?
Michael Valente: Hospitalizations usually range between seven to 10 days on average, sometimes a little longer. Complications historically have been moderate to high in this patient population due to the intensity of the type of operation that we're doing. But with that being said, especially here at the Cleveland Clinic, most of our patients do not go to the intensive care unit after the operation, they go to the normal nursing floor. Some of the more common complications would be, with any operation, bleeding, infection, wound infections, urinary tract infections, et cetera.
Scott Steele: So when you talk about what's on the frontier, what's on the horizon for this type of procedure, what in your mind are going to be some of the next things that may come up in terms of evolution for the cytoreductive surgery and for HIPEC?
Michael Valente: I think for colorectal metastasis there's still a lot of research being done, particularly in this era of looking at is it more of the actual cytoreductive part that's doing the best, or is it a combination of adding the chemotherapy. So we don't 100% know right now, but I will say for right now, colorectal metastasis to the peritoneal lining would receive cytoreductive surgery plus the HIPEC procedure.
I think another frontier that's being explored, especially in European countries, is a procedure called PIPEC, P-I-P-E-C, which is essentially chemotherapy that's aerosolized, where they put small laparoscopes in and spray the chemotherapy into the abdominal cavity in a much more minimally invasive approach. But those are for more advanced tumors as well, maybe ones who couldn't receive ... I talked about those ones where we had to abort, maybe those procedures may be beneficial for them. But that's still under FDA review.
Scott Steele: So again, I think this is something that our patients can know, is that it is something that we do offer here and it's something that we try to go out of our way to pick the select patients that will get the benefit from this, and putting in as minimal amount of harm as possible. Mike, that's fantastic stuff, and as you know, we always like to wind up just asking a couple of quick hitters with each of our guests, and since you've been on here before we've got some new ones for you. First of all, do you listen to music in the operating room, and if so, what kind?
Michael Valente: I absolutely listen to music in the operating room. It's a combination of classic rock and roll or classical music.
Scott Steele: And then what's the best trip, what's the best place that you've ever been to on a trip?
Michael Valente: I just had the best vacation of my life where I took my parents, my three children, and my wife to my mom's hometown in Northern Italy. It was just the most wonderful time.
Scott Steele: Mike, is there a food, number three, that you just will not eat?
Michael Valente: Haven't found it yet.
Scott Steele: That's fantastic. And then finally, what's a hidden gem here in the state of Ohio, someplace that you say, "You know what? You live here, you come here, this is a place maybe you won't see or hear a lot about, but you should go visit"?
Michael Valente: Great question. My favorite place in Ohio would be the Hocking Hills State Forest down by Athens, Ohio, where I did my medical school. It's the Old Man's Cave area, just a beautiful array of old glacier formations and sedimentary rock structures, beautiful hiking and waterfalls there.
Scott Steele: That's a fantastic thing and a great tip. For more information about Cleveland Clinic's HIPEC program, and to access a free treatment guide, please visit clevelandclinic.org/HIPEC, that again is H-I-P-E-C, that's clevelandclinic.org/HIPEC. And to schedule a consultation with a Cleveland Clinic specialist, please call (216) 444-7000, that's (216) 444-7000. Mike, thanks for joining us on Butts & Guts.
Michael Valente: Thanks for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.