Cancers that originate in the abdomen and spread throughout the peritoneal cavity used to be universally fatal, says surgeon Fabian Johnston, who joined the Johns Hopkins faculty in May 2016. Surgically removing the many metastatic sites seemed like an impossible task, and systemically delivered chemotherapy doesn’t penetrate deep enough into the peritoneal lining to catch budding, as-yet-invisible tumors.
However, he explains, a technique that’s been slowly gathering steam over the past few decades could offer patients a chance at extended survival or even a cure. Known as hyperthermic intraperitoneal chemotherapy, or HIPEC, it involves flooding the cavity with a warm chemotherapy solution, catching errant malignant cells and small, imperceptible tumors before they develop a foothold in the abdomen or metastasize elsewhere in the body.
The treatment can be an option for patients with appendiceal, colon, ovarian, gastric or primary peritoneal cancers, Johnston says, because these cancers tend to spread locally at first, colonizing the peritoneal cavity. To perform HIPEC, he and the surgical team must first perform a complete cytoreduction of all visible disease throughout the entire abdomen, checking for evidence of lesions on the diaphragm, liver, bladder, bowel and paracolic gutters—anywhere cancerous cells might have traveled throughout the cavity. This initial part of the procedure might take two hours or up to 12 depending on the extent of cancer spread.
“It’s a very exhaustive surgery to get patients down to an extremely low level of disease,” Johnston says.
Once cytoreduction is complete, the next step is to fill the peritoneal cavity with a chemotherapeutic solution heated to 42 degrees Celsius, about the temperature of a warm bath, and allow it to circulate up to 90 minutes. Heating the solution allows the selected chemotherapeutic drug to enter cells more easily, increasing its killing power. But since its activity is confined to the abdomen, patients avoid some side effects common with systemically delivered chemotherapies.
Performing HIPEC successfully isn’t possible without a multidisciplinary team with expertise on this technique, Johnston says, which isn’t available at many institutions. For example, he says, due to the nature of these cancers, many patients aren’t optimally nourished before surgery. Working with nutritionists gets patients on track before HIPEC, which helps ease the postoperative period. Anesthesiologists familiar with HIPEC also use protocols that fast-track recovery, including epidurals instead of narcotics and minimal use of fluid, which allow patients’ bowels to recover faster and let patients receive oral nutrition earlier.
“I always tell patients that this procedure is a marathon,” Johnston says. “HIPEC is like nothing they’ve ever been through before. Our entire team works together to give patients the best recovery and outcome.”
Besides achieving excellent clinical outcomes, Johnston notes that it’s important for him and other surgical team members to make sure that patients and their families are cared for like family.
“We hold the entire team,” he says, “to the same standard of care we’d want for our own families.”