December 20, 2019
A procedure introduced in the 1980s to treat low-grade appendiceal cancer is gaining traction in the fight against abdominal cancers. Early diagnosis and referral to a high-volume cancer center are imperative.
The leadership of The University of Kansas Cancer Center is passionate about innovative surgical oncology and committed to delivering revolutionary cancer care. When I first joined the cancer center, I performed a wide variety of oncology procedures. Then I began to specialize in a complex operation called CRS-HIPEC. It stands for cytoreductive surgery with hyperthermic intraoperative intraperitoneal chemotherapy.
CRS-HIPEC has been a standard treatment for low-grade appendiceal cancer for nearly 40 years. In 2003, The University of Kansas Health System was at the forefront of a national trend to expand the use of CRS-HIPEC to other abdominal cancers that behave like cancer of the appendix.
Cancer cells can spread within an organ – from the tumor itself to the surrounding tissue. They can also spread through the bloodstream. These malignancies often respond to traditional IV or oral chemotherapy. But there are several cancers that spread in a more sinister manner.
Tumors of the appendix, colon, ovaries and stomach sometimes penetrate the wall of the organ of the tumor's origin and shed cells throughout the abdominal cavity. The cells land like tiny seeds on the surfaces of organs and tissues where widespread tumors develop. This peritoneal metastasis or peritoneal carcinomatosis can be very difficult to control.
CRS-HIPEC gives select patients with peritoneal carcinomatosis a chance at survival. During cytoreductive surgery, we expose the entire abdominal cavity and remove any visible evidence of cancer. It's a painstaking process that can take as many as 15 hours.
When we have completed a thorough cytoreduction, we follow with HIPEC. This direct delivery method has many benefits over traditional IV or oral chemotherapy. Bathing the organs and abdominal lining in a chemotherapy solution allows us to destroy any remaining microscopic cancer cells or hidden tumors. The heated solution penetrates the tissue more deeply. Plus, the medication dose can be much higher with fewer toxic side effects.
The largest randomized study to date reports a doubling in survival among patients with colorectal cancer who had CRS-HIPEC when compared to patients who had standard chemotherapy alone. In gynecologic patients, CRS-HIPEC resulted in longer recurrence-free survival and overall survival.
Studies show patients benefit when they receive CRS-HIPEC at a high-volume center. Complication rates are lower, and outcomes are better. A high-volume center is defined as one that has completed 140 procedures.
At The University of Kansas Cancer Center, we far exceed that number. I have performed hundreds of CRS-HIPEC operations. Our team completes 1 almost every week.
Some institutions perform a few CRS-HIPEC procedures, perhaps only 3 or so per year. It is important to refer patients to a facility with deep experience to optimize patient safety and outcomes. We are the only hospital in the Kansas City area, the entire state of Kansas and western Missouri with the case volume required to perform CRS-HIPEC safely and effectively.
As the region's only National Cancer Institute-designated cancer center, we also offer a multidisciplinary support team. Our specialists include surgeons, nurses, ICU staff, counselors, nutritionists and physical therapists. They provide expert care for patients before, during and after the complicated procedure.
Patient selection is key
If you have a patient with peritoneal carcinomatosis, consider these 3 criteria to identify candidates for CRS-HIPEC:
- The patient's peritoneal surface disease must arise from appendiceal, colon, ovarian or stomach cancer, or abdominal mesothelioma.
- The patient's cancer must not have metastasized beyond the abdominal cavity to the lungs or bones.
- The patient must not have multiple medical issues.
If your patient is a fit, it's time to reach out to an experienced surgical oncologist at a high-volume CRS-HIPEC center. We will review the history, complete a physical exam and study new pathology and radiology reports. If CRS-HIPEC is right, we will send your patient back to your care for neoadjuvant, systemic IV chemotherapy.
We use an abundance of caution when proceeding with this aggressive therapy. In fact, our surgeons sometimes stop the procedure after a visual inspection of the patient's abdomen. In approximately 25-30% of cases, we discover the disease is too widespread for a safe and effective cytoreductive surgery.
A bright future
CRS-HIPEC is not for every cancer patient. And it is not without controversy. The biggest challenges are selecting the right candidates and fine-tuning the chemotherapy agents. As with all healthcare advances, it's only a matter of time and clinical trials before we determine the perfect balance.
At The University of Kansas Cancer Center, we have CRS-HIPEC patients who tell me we saved their lives. Some have undergone the procedure a second time. Most feel lucky to live near a hospital that invests time, money and resources in a treatment that other local facilities know little to nothing about.
I believe there are cancer patients in our region who could benefit from this advanced therapy. If you have a patient with peritoneal carcinomatosis, please contact us for more information. A timely referral is of the essence.
Dr. Al-kasspooles' surgical oncology specialties include gastrointestinal malignancies and esophageal cancer. He incorporates endoscopy and minimally invasive procedures when applicable. Dr. Al-kasspooles is committed to providing compassionate state-of-the-art oncologic surgical care as part of a multidisciplinary approach to patients diagnosed with cancer.
Clinical trial opportunity
The purpose of this trial is to compare the morbidity and mortality of CRS-HIPEC using mitomycin-C versus melphalan. It is designed for patients 18-75 years of age who have peritoneal surface disease (PSD) due to colorectal cancer or high-grade appendiceal cancer.