Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Peritoneal chemotherapy refers to liquid chemotherapy solution that is poured directly into the abdomen (called the peritoneal cavity). Chemotherapy solution is a liquid chemical solution that kills cancer cells. Higher concentrations of the chemotherapy solution can be used when it is given directly into the abdomen, so chemotherapy given this way is more effective at killing cancer cells in the abdomen than chemotherapy that is given IV (through a vein). Chemotherapy given this way also causes fewer side effects than chemotherapy given IV because of something in the body called the “peritoneal-plasma barrier” that prevents the high concentrations of chemotherapy solution from reaching the blood stream.
A newer treatment for cancer that has spread into the abdomen is Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC). Intraoperative means the chemotherapy solution is poured into the abdomen (peritoneal cavity) while the patient is still in surgery at the time of the cytoreduction (debulking) surgery. The chemotherapy solution is heated to a temperature higher than normal body temperature (hyperthermic). When the chemotherapy solution is heated, it is thought to be more effective in killing cancer cells.
This procedure is done because the chemotherapy can reach more places in the abdomen while the abdomen is still open for surgery (it can be swished around and circulated inside the abdomen to reach more areas where cancer cells that are not visible to the naked eye may be hiding). In some cases the chemo is circulated through tubes in the abdomen after the abdomen has been closed (closed technique).
This type of chemotherapy is best at killing cancer cells that are too small to be seen with the naked eye- these include cancer cells that may have been released from larger tumors during the surgery or cells that have been released if the appendix has perforated or ruptured. Peritoneal chemotherapy prevents these cells from being left behind to form new cancerous tumors in the abdomen.
It is felt that this type of chemotherapy is most effective during and immediately following the cytoreduction surgery, before scar tissue and adhesions have a chance to form. Once scar tissue and adhesions have formed, it is felt the chemotherapy will be less likely to reach all surfaces in the abdomen and therefore the therapy will likely be less effective.
Patients at high risk for having cancer cells in the abdomen too small to be seen that remain after the larger tumors are removed (microscopic residual disease) are those with:
- scattered small tumors in the abdomen (“peritoneal seeding”)
- cancer that has ruptured the wall of the appendix (perforated cancer)
- cancer cells discovered in fluid from the abdomen when the fluid is viewed under a microscope (positive peritoneal cytology)
- cancer that has spread to the ovaries
- cancer found on organs adjacent to the appendix tumor.
The debulking surgery itself removes only tumors visible to the naked eye. Peritoneal chemotherapy destroys cells and tumors left behind that are too small to be seen. The goal of HIPEC is to prevent these cells from growing into new tumors in the future and causing a recurrence of the cancer.
A slang phrase used for this combination debulking surgery and intraperitoneal chemotherapy treatment is “shake and bake”; “shake” referring to the swishing around of the chemotherapy solution in the abdomen while in surgery and “bake” referring to the higher temperature of the chemotherapy solution.
Not all medical facilities are able to provide Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC). A list of facilities and physicians I have been in contact with who are able to offer these cytoreduction (debulking) surgeries, peritoneal chemotherapy and hyperthermic intraoperative peritoneal chemotherapy treatments and who specialize in appendix cancer treatments are listed on this page of my web site: Physician Specialists and Facilities.
When unheated peritoneal chemotherapy is administered into the abdomen after the surgery is over, a tube or port is surgically placed to allow the solution to be instilled into the abdomen. The tube most often used is called a Tenckhoff catheter, a catheter (tube) that is also commonly used for peritoneal dialysis. In other cases a Portacath such as the one used for IV chemotherapy is surgically implanted in the abdomen. Sometimes this type of chemotherapy is done for several days in a row or for several cycles immediately following the cytoreduction (debulking) surgery in the early post-operative (after surgery) days. This is referred to as Early Postoperative Intraperitoneal Chemotherapy (EPIC).
Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC) is also done for other cancers that have spread to the peritoneal surfaces of the abdomen after cytoreduction (debulking) surgery is completed, such as ovarian, colon, gastric and pancreatic cancers.
Most of the specialist listed on my website treat these other cancers along with appendiceal cancer. Many of the current clinical trials using this therapy include appendiceal cancer with other GI cancers that have metastasized into the abdomen. Since appendiceal is an orphan disease, we benefit from this inclusion in research studies.
For those of you who don’t know what an orphan disease is, it is a disease that effects so few people that it is essentially “orphaned” in medical research. My daughter, who was 10 years old at the time of my diagnosis understood my cancer was very rare. She came up to me one day as I was searching for treatment and said “Mom, no one is going to try real hard to cure appendix cancer, are they? It would cost too much money and help too few people”. She understood exactly what was meant by an orphan disease, it is a disease that is not cost-effective to attempt to cure. Remember the movie “Lorenzo’s Oil”?
Appendiceal cancer most often kills by spread into the abdomen (peritoneal surface malignancy) and interference with with digestion and the functioning of organs in the abdomen. Because of this, it can be grouped in research with diseases that can kill in the same way but are more common…ovarian, colon, gastric etc. that can also cause “peritoneal surface malignancies”.
Comparison of two kinds of intraperitoneal chemotherapy following complete cytoreductive surgery of colorectal peritoneal carcinomatosis.
Advanced Colorectal Cancer: Consensus Group Recommends Heated Chemotherapy after Surgery, but Other Experts Disagree, Citing Need for Phase III Data
Perioperative intraperitoneal chemotherapy for peritoneal surface malignancy
Appendiceal neoplasms with peritoneal dissemination: outcomes after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy.
Long-Term Survivorship and Quality of Life After Cytoreductive Surgery Plus Intraperitoneal Hyperthermic Chemotherapy for Peritoneal Carcinomatosis