Preoperative Evaluation for Cytoreductive Surgery and HIPEC in Peritoneal Metastases

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• Preoperative Assessment Importance
• Prognostic Indicators Evaluation
• Cytoreductive Surgery Process
• Heated Chemotherapy (HIPEC)
• Multidisciplinary Treatment Integration
• Full Transcript

Preoperative Assessment Importance

Preoperative assessment is an extremely important first step for patients diagnosed with peritoneal metastases. Dr. Paul Sugarbaker, MD, emphasizes that this evaluation determines if a patient will benefit from cytoreductive surgery and HIPEC. The process is not simple and involves a thorough review of the patient's condition and cancer type.

This initial workup helps the medical team create a precise treatment strategy. It ensures that only suitable candidates proceed with the intensive surgical and chemotherapy procedure.

Prognostic Indicators Evaluation

Evaluating prognostic indicators is a critical component of the preoperative assessment. Dr. Paul Sugarbaker, MD, states this involves a CT scan and an assessment of the patient's performance status. A preoperative review of the tumor's pathology is also essential to confirm the primary cancer type, such as colon, gastric, or ovarian cancer.

This comprehensive evaluation helps predict treatment outcomes. It ensures the selected therapy aligns with the specific biology of the patient's metastatic disease.

Cytoreductive Surgery Process

The cytoreductive surgery process involves a major abdominal incision and can last six to ten hours. Dr. Paul Sugarbaker, MD, explains the goal is to remove every visible piece of peritoneal cancer metastasis. The surgery aims to eliminate the disease down to the cellular level, which is why it is called cytoreduction.

This meticulous removal of all visible tumor is the foundation for a successful outcome. It prepares the abdominal cavity for the next critical phase of treatment.

Heated Chemotherapy (HIPEC)

Heated chemotherapy, or HIPEC, is administered immediately after cytoreductive surgery. Dr. Paul Sugarbaker, MD, describes flooding the abdomen with a large volume of warm chemotherapy solution. This targets minimal residual disease, including free cancer cells and micrometastases that are invisible to the surgeon.

The heat enhances the chemotherapy's effectiveness against these microscopic cancer deposits. This regional treatment is a crucial step in preventing disease recurrence and improving survival.

Multidisciplinary Treatment Integration

Multidisciplinary treatment integration is vital for managing peritoneal metastases. Dr. Paul Sugarbaker, MD, clarifies that HIPEC is added to appropriate systemic chemotherapy, not used in exclusion. The patient's care is followed by a multidisciplinary team long after the procedure is complete.

This combined approach addresses both the macroscopic and microscopic disease in the abdomen and any systemic spread. Dr. Anton Titov, MD, highlights that this comprehensive strategy offers a potential for cure in selected patients with advanced cancers.

Full Transcript

Dr. Anton Titov, MD: Before we get into more details of the Sugarbaker Procedure to treat peritoneal cancer metastases, what is the overall treatment strategy when a patient is diagnosed with cancer metastases into the peritoneal space?

Dr. Anton Titov, MD: What is a high-level picture of cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? What happens when someone is diagnosed with abdominal cancer metastases to the peritoneal space—metastases from colon cancer, gastric cancer, ovarian cancer, or appendiceal cancer?

Dr. Paul Sugarbaker, MD: It is very important before peritoneal cancer metastases treatment to assess the prognostic indicators. Metastases from primary cancer—colon cancer, gastric cancer, or ovarian cancer—prognostic indicators in peritoneal cancer tell if this patient is going to profit from cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

This preoperative assessment after peritoneal cancer diagnosis is very important. It is not so easy to do. Preoperative assessment of peritoneal metastatic cancer patient involves the CT scan. It involves an assessment of the patient's performance status.

Preoperative review of the pathology of underlying tumor seeks to determine the type of malignancy—for example, colon cancer, gastric cancer, ovarian cancer, appendiceal cancer.

Dr. Anton Titov, MD: What kind of cancer has spread into peritoneal space? Preoperative assessment is extremely important.

Dr. Paul Sugarbaker, MD: Sometimes the peritoneal metastatic cancer patient is considered by a multidisciplinary team to be a candidate for cytoreductive surgery; then they go to the operating room. Usually we first do cytoreductive surgery. Sometimes we want to give peritoneal metastatic cancer patients a limited course of cancer chemotherapy first.

Dr. Anton Titov, MD: We call that neoadjuvant chemotherapy.

Dr. Paul Sugarbaker, MD: But for the most part, patients go straight to the operating room. In cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC), we make a big abdominal incision. Patients can have six hours or eight hours or ten hours of surgery in order to remove every last piece of peritoneal cancer.

All the visible component of the peritoneal cancer metastases should be removed. In doing the cytoreductive surgery, we want to remove the cancer metastases in the peritoneum down to the cellular level. That's why it is called cytoreductive surgery.

After cytoreductive surgery, we flood the abdomen with a large volume of warm chemotherapy solution. That is an attempt to eradicate what we call minimal residual disease. It is peritoneal metastatic cancer cells that the surgeon does not see.

It is what the surgeon does not see that kills the patient.

Dr. Anton Titov, MD: It is metastatic disease that usually kills the patient—the micro-metastases.

Dr. Paul Sugarbaker, MD: Yes, micrometastatic disease. We are trying to get rid of those free cancer cells and micrometastatic disease by Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Dr. Anton Titov, MD: Then after the cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) procedure, the patient is followed by a multidisciplinary team. The histology nature of the cancer that metastasized into the peritoneum is known.

Dr. Paul Sugarbaker, MD: That is correct. For the most part, the cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is added on to the appropriate systemic chemotherapy. We add cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to the primary chemotherapy of patient's cancer—colon cancer, gastric cancer, abdominal cancer, or appendiceal cancer.

Because this is a treatment in addition to systemic chemotherapy and not exclusive of systemic chemotherapy.

Dr. Anton Titov, MD: Peritoneal metastases cancer treatment options: heated chemotherapy and cytoreductive surgery. Cancer surgeon explains stage 4 cancer treatment by HIPEC.