Cancer has always been a global health challenge, and as the disease progresses and spreads within the abdominal or pelvic cavity, treatment becomes more complex.
In this context, an advanced therapeutic approach emerges, combining surgical prowess with the effectiveness of chemotherapy.
This is what is now known as Cytoreductive Surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), or “heated chemotherapy” for short.
This combined therapy is not just a medical procedure; it is an integrated strategy aimed at achieving maximum tumor removal and improving cure rates for patients with widespread cancers in the peritoneal membrane.
This approach enhances the effectiveness of the surgical procedure and improves patient outcomes.
One of the prominent centers offering this treatment is Liva Hospital in Turkey, where operations are performed under strict protocols using advanced techniques.
What is Peritoneal Carcinomatosis?
Peritoneal carcinomatosis refers to the spread of cancer cells to the peritoneum, the thin membrane that lines the abdominal and pelvic cavities and covers most internal organs.
This spread often occurs as part of advanced stages of gastrointestinal cancers (such as colorectal cancer, stomach cancer, appendiceal cancer) or ovarian cancer.
Previously, the spread of cancer to the peritoneum was considered an indicator of an incurable disease with a short average survival time.
However, thanks to advances in understanding cancer biology and the development of innovative surgical and therapeutic techniques, there is a new glimmer of hope.
This hope lies in the combined approach of Cytoreductive Surgery (CRS), which aims to remove as much visible tumor as possible from the abdominal cavity, followed by Hyperthermic Intraperitoneal Chemotherapy (HIPEC), which targets remaining microscopic cancer cells.
This comprehensive approach treats the disease on two levels:
- The first is the surgical removal of large cancerous masses.
- The second is the precise elimination of cancerous cells disseminated throughout the peritoneal cavity, which significantly increases the chances of achieving a cure or prolonging survival and improving the quality of life for patients who previously faced a difficult prognosis.
Cytoreductive Surgery (CRS)
Cytoreductive Surgery (CRS) is the first and essential stage in this complex therapeutic approach.
This surgery is not limited to removing the primary tumor but extends to include the removal of all visible cancerous clusters spread on the surface of the peritoneal membrane and internal organs.
This procedure requires exceptional surgical skill and extensive experience, as it may involve removing parts of the small and large intestines, spleen, part of the stomach, gallbladder, diaphragm, and abdominal and pelvic walls, depending on the extent of cancer spread.
The primary goal of CRS is to reduce tumor volume as much as possible, preferably with a complete removal of visible cancer (R0 or R1 resection), as studies have shown that the degree of complete resection is the most important factor in determining the patient’s long-term outcomes.
This complex surgery can take many hours and requires a highly skilled and experienced surgical team for this type of procedure, where each cancerous cluster is evaluated and removed with extreme precision.
The success of this stage is key to the effectiveness of the subsequent HIPEC.
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
After completing the cytoreductive surgery and removing all visible tumors, the second and vital phase of treatment begins: Hyperthermic Intraperitoneal Chemotherapy (HIPEC).
In this stage, a sterile solution of chemotherapy drugs (carefully selected based on the type of cancer) is directly introduced into the abdominal cavity.
This precise technique requires specialized equipment and continuous temperature monitoring to ensure maximum effectiveness while maintaining patient safety.
This distinguishes specialized medical centers in this type of treatment, such as Liva Hospital in Turkey, where the latest protocols are applied to ensure the best results.
This solution is heated to a temperature typically ranging between 41 and 43 degrees Celsius and circulated within the abdominal cavity for 30 to 120 minutes. The combination of heat and chemotherapy has several unique advantages:
- Synergistic Effect: Heat itself has a cytotoxic effect on cancer cells and increases the sensitivity of these cells to chemotherapy drugs, enhancing their effectiveness.
- Direct Delivery: Intraperitoneal infusion ensures that the chemotherapy drug reaches cancer cells spread on the peritoneal membrane and in fluids at a high, direct concentration, while minimizing systemic absorption of the drug. This reduces the overall side effects of traditional intravenous chemotherapy.
- Elimination of Microscopic Cells: HIPEC targets microscopic cancer cells that may not be visible to the naked eye or imaging tests, and which cannot be removed by surgery alone.
Preparation and Post-Surgical Care
Tumor debulking and HIPEC are major procedures that require preparation and intensive post-surgical care to ensure the best possible outcomes and minimize complications.
The preparation phase begins with a comprehensive multidisciplinary evaluation of the patient to ensure their suitability for this complex procedure.
This includes advanced imaging tests to assess the extent of tumor spread, and tests of heart, lung, kidney, and liver function to ensure the body’s ability to tolerate surgery and chemotherapy.
Nutritional status may also need to be improved before surgery.
Detailed discussions with the patient and their family about the procedure, risks, and expected outcomes are an essential part of the preparation.
Post-surgical care is intensive and takes place in the intensive care unit or high-dependency unit.
The patient is closely monitored for vital signs, organ functions, and any signs of complications. Care includes effective pain management, control of nausea and vomiting, and monitoring of fluid and electrolyte balance.
Due to the long duration of the operation and its effect on the digestive system, the patient may initially require intravenous nutritional support, followed by gradual oral feeding.
Early physical therapy and rehabilitation play a vital role in restoring the patient’s strength and mobility. Psychological support for the patient and their family is also essential during this difficult phase.
Challenges and Potential Complications
Despite the significant benefits offered by cytoreductive surgery and HIPEC, it is a complex procedure that carries some potential challenges and complications that the patient and their medical team must be aware of and prepared to manage. Common post-surgical complications include:
- Infection: At the surgical site, inside the abdomen (abscesses), or in the respiratory system.
- Bleeding: Either during or after surgery.
- Bowel problems: Such as bowel obstruction, leakage from surgical anastomoses, or delayed return of bowel function (ileus).
- Organ damage: Some adjacent organs may be damaged during extensive resection.
- Chemotherapy side effects: Although systemic absorption is lower, some side effects of chemotherapy may occur, such as kidney dysfunction, liver damage, or bone marrow suppression (low blood cell count).
- Nutrition: Some patients may face long-term nutritional difficulties.
When is Tumor Debulking and HIPEC a Treatment Option?
The decision to resort to cytoreductive surgery and HIPEC is not an easy one and requires a meticulous evaluation of each case by a multidisciplinary medical team.
This therapeutic approach is not suitable for all patients with peritoneal carcinomatosis. The main criteria considered include:
- Type of Cancer: The treatment is most effective in certain cancers such as colorectal cancer metastasized to the peritoneum, pseudomyxoma peritonei (a type of appendiceal cancer), advanced ovarian cancer, and some cases of stomach cancer metastasized to the peritoneum.
- Extent of Cancer Spread (Tumor Burden): The cancer must be almost completely resectable (less than 2.5 mm of residual tumors after surgery). If there is very widespread dissemination that is difficult to remove completely, this treatment may not be suitable.
- Patient’s General Health (Performance Status): The patient must be in good enough health to tolerate major, long-duration surgery and intensive chemotherapy.
- Absence of Distant Metastases: The cancer must not have spread to distant organs outside the abdominal cavity (such as the lungs or liver).
Conclusion
In conclusion, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) represents a revolution in the treatment of cancers that have spread to the peritoneal membrane.
This approach has transformed from an experimental treatment to a standard of care for carefully selected patients, offering them new hope for cure or prolonged survival and improved quality of life, something that was previously impossible.
Despite the complexities of this procedure and potential complications, continuous advancements in surgical techniques, care protocols, and accumulated expertise among specialized medical teams in centers like Liva Hospital in Turkey have made this treatment safer and more effective.
Frequently Asked Questions
Is heated chemotherapy painful?
The patient does not feel pain during the application of heated chemotherapy, as it is performed while the patient is completely anesthetized after the surgery is completed. Pain after the operation is effectively controlled using painkillers.
What types of cancers can be treated with CRS/HIPEC?
This treatment is primarily used for colorectal cancers that have spread to the peritoneum, pseudomyxoma peritonei, advanced ovarian cancer, and some cases of stomach cancer that have spread to the peritoneum.
How long is the hospital stay after the operation?
Given that it is a major operation, the hospital stay usually ranges between two and three weeks and may increase or decrease depending on the patient’s recovery and the presence of any complications.
Can cancer occur after this treatment?
Although this treatment aims to comprehensively eliminate cancer, there is always a possibility of disease recurrence, especially in advanced cancer cases. Therefore, regular follow-up and examinations are necessary after treatment.
Can this treatment be performed in all hospitals?
No, heated chemotherapy and cytoreductive surgery require specialized surgical expertise, a multidisciplinary team, and advanced equipment. Therefore, it is performed only in specialized medical centers that have experience in complex oncological surgery.
What is the quality of life after CRS/HIPEC?
This procedure aims to improve the patient’s long-term quality of life by controlling cancer. Despite a difficult initial recovery period, most patients return to a normal or near-normal life after full recovery and are able to perform their daily activities.
