Bathing the abdomen in heated chemotherapy as part of surgery improves survival.
Most people think of the lungs when they think of mesothelioma, a cancer caused definitively by exposure to asbestos fibers that oncologists typically treat with systemic chemotherapy. But for people diagnosed with peritoneal mesothelioma, a form of the cancer which attacks the lining of the abdomen, a complicated treatment called cytoreductive surgery hyperthermic intraperitoneal chemoperfusion, or CS/HIPEC, has become a standard of care option with potential to cure the disease.
“The results are quite impressive. About 80% of patients who are eligible for the treatment will be alive at five years after, and about half of that number without any further evidence of disease,” says surgeon Joseph Skitzki, MD, Associate Professor of Oncology at Roswell Park Comprehensive Cancer Center.
“We’ve been doing CS/HIPEC at Roswell Park since 2002, so our team is very well versed in the procedure. Not just our operating room team, but most importantly the anesthesiologist, and the recovery teams on the floor. We have good pathways established in terms of how patients are going to do and how they recover.”
How does CS/HIPEC work?
The treatment involves extensive surgery to remove the cancer followed by delivering heated chemotherapy directly to the abdomen before the operation is completed. It has been an accepted treatment since the mid-1990s for cancers that involve the peritoneum, the smooth serous membrane that lines the abdomen and covers most abdominal organs. Complicated but highly effective, CS/HIPEC is a treatment for appendix, ovarian and colon cancer as well as mesothelioma.
“This is a good option for peritoneal mesothelioma because it’s designed not only to remove the detectable disease but to treat any microscopic cells that may not be visible at the time of the surgery,” says Dr. Skitzki.
It removes all evidence of mesothelioma cancer and disease sites and offers a good chance of preventing the peritoneal cancer from coming back. First, the surgeon removes all visible cancerous tumors from the abdominal cavity, then saturates the cavity with a chemotherapy solution heated to 42 degrees Celsius.
“We circulate this for 90 minutes, right after we remove all the disease we can see and feel. At the end of 90 minutes, we let all that chemotherapy drain out. Then we wash out any remaining chemo from the abdomen and close it,” Dr. Skitzki says.
Why is the chemotherapy solution heated?
There is a blood-peritoneal barrier found in peritoneal mesothelioma that limits the penetration of traditional chemotherapy, and temperatures above 42 degrees Celsius are known to kill tumor cells. The heated solution provides eight to 10 times more drug concentration and helps prevent the harmful side effects that happen with IV chemo delivery.
“The heat improves chemotherapy uptake and helps kill the microscopic disease we may not be able to see,” Skitzki explains. “We give the chemotherapy directly to the abdomen to overcome the blood-peritoneal barrier and get drug concentrations that are much higher than you can get through systemic IV. The chemotherapy drug that we use has very predictable side effects and is less toxic when we give it directly to the abdomen.”
Who is eligible for CS/HIPEC treatment for mesothelioma?
Not all patients are able to undergo the treatment. Patients who are good candidates must meet three important criteria. The patient must first be strong enough to tolerate a “big surgery” that can last from eight to 10 hours. They must have “good performance status,” advises Dr. Skitzki.
A patient also must have cancer that is isolated to the abdomen, which may depend on the type of mesothelioma tumors present and there are three kinds.
“The most common type is epithelioid, which is the most responsive to treatment and has the highest potential for cure. Another one is sarcomatoid. That’s a little bit more difficult to treat because they tend to behave a little more aggressively. Then there’s the mixed type, which can also behave aggressively,” Dr. Skitzki says.
“Fortunately, the majority of mesotheliomas that occur in the abdomen are epithelioid and they seem to respond best for potential survival and long-term cure.”
The third criterion for CS/HIPEC is that the surgeon will be able to remove all of the cancer deposits completely.
“The mesothelioma should be something we can completely remove, and we can tell that based on their scans. If it’s both in the chest and the abdomen, sometimes we must think about either sequential treatment or that maybe surgery is not going to be the best option.” Dr. Skitzki explains.
Systemic chemotherapy, while unlikely to be curative, may be a good option to prolong survival in patients who do not meet these criteria, he adds. Most patients tolerate the CS/HIPEC treatment well and are active the day after the surgery with recovery, discharged within 10 days, and back to normal baseline function within three months.
“If somebody does have peritoneal mesothelioma, they should know there are treatments besides systemic chemotherapy available, and that if they are a candidate for a more aggressive treatment like cytoreductive HIPEC, I think it is worthwhile to discuss with their oncologist, or come discuss it with us,” says Dr. Skitzki.
“It would require a surgical consult. Patient selection is important and since Roswell Park is experienced in cytoreductive surgery, we’ve shown to be pretty good at that.”