Treatment options for peritoneal carcinomatosis remain limited and the prognosis is guarded. Cytoreductive surgery combined with the administration of hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective alternative for patients with disease of limited extent, and which does not involve areas known to be unresectable (such as very extensive involvement of the surface of the small bowel, hepatic hilum, etc.).
What is HIPEC?
HIPEC consists of the administration of chemotherapy at a temperature between 40-43°C for a specific time, between 60-120 minutes, at the end of the cytoreduction surgery procedure. However, not all patients with peritoneal carcinomatosis are suitable for HIPEC.
Types of cancer for which it is recommended
The primary tumor may be located in:
- Abdomen: stomach, colon, small intestine, ovary, pancreas, endometrium, appendix (one of its variants is peritoneal Pseudomyxoma), sarcoma, cholangiocarcinoma, kidney cancer.
- Outside the abdomen: lung cancer, breast cancer, melanoma.
- In the peritoneum itself: peritoneal mesothelioma, primary peritoneal cancer.
Who is a candidate for HIPEC?
Candidate selection is based on several key factors.
- Extent of disease. The Peritoneal Carcinomatosis Index (PCI) is used to assess the extent of disease.A low PCI indicates that the disease is less widespread and that there is a greater chance of success with HIPEC.
- Distant metastases. It is necessary to evaluate whether the patient has distant metastatic disease to the peritoneum or not.That is, if there are metastases in the lungs, liver or bones.
- General condition of the patient. Patients should be in general physical condition to withstand both cytoreductive surgery and HIPEC.This includes a thorough assessment of health status, vital functions and ability to recover.
- Type of primary tumor. The primary tumor may be located inside the abdomen, outside the abdomen or in the peritoneum itself.
All patients with peritoneal disease should be evaluated in a Peritoneal Surgery Unit, by a Peritoneal Pathology Expert Committee.
Alternatives for patients who are not candidates for HIPEC
When the patient is not a candidate for cytoreduction surgery and HIPEC, the alternative is systemic chemotherapy and some advanced intaeperitoneal therapy techniques such as PIPAC or ePIPAC . However, systemic chemotherapy is less effective in the peritoneum than in other organs, as it receives only 3% to 6% of the blood flow. Because of its poor vascularization, even if the blood is loaded with chemotherapy, very little reaches the peritoneum.
Prehabilitation of patients
Prehabilitation of patients is performed when the disease is operable to minimize postoperative complications. It is also an alternative when the patient’s general condition does not allow it because of the risk involved. This circuit tries to optimize the patient’s general condition so that he/she can be operated on.
The Viamed Institute of Advanced Oncological Surgery (IVOQA) provides a comprehensive prehabilitation program that involves its entire multidisciplinary team, including internists, endocrinologists, physical rehabilitators, respiratory rehabilitators, psycho-oncologists and hematologists, among other specialists. This program is designed to prepare the patient before surgery, with the aim of optimizing his or her physical and emotional state so that he or she can face the surgical intervention in the best possible conditions.
- Nutritional prehabilitation: the patient’s nutritional status is assessed, measures are taken according to their nutritional status, supplements are prescribed. In some cases, hospitalization may be required for intravenous nutrition.
- Physical prehabilitation: exercise and rehabilitation program in a gym if necessary and/or at home through our app.
- Respiratory prehabilitation: they learn and exercise respiratory physiotherapy exercises before surgery and in the postoperative period.
- Hematological prehabilitation: hematologists analyze bone marrow function in patients who have received chemotherapy and evaluate their response capacity.
- Psychological prehabilitation: assessment by a psycho-oncologist is a fundamental part of the patient’s and family’s ability to face surgery and the whole oncologic process.
ERAS® protocol in the postoperative period
For its part, IVOQA has implemented the ERAS® protocol guidelines throughout its care process. The ERAS® protocols (Enhanced Recovery After Surgery) are a set of multidisciplinary perioperative strategies aimed at reducing hospitalization times, recovery and perioperative complications.
In conclusion, the selection of patients with peritoneal carcinomatosis who are candidates for HIPEC is a thorough process that requires consideration of the extent of the disease, the presence of distant metastases and the patient’s general condition. For those unsuitable for HIPEC, alternatives such as systemic chemotherapy and advanced intraperitoneal therapies are available. Prehabilitation and ERAS® protocols are essential to optimize recovery and improve postoperative outcomes.
