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Heated intraoperative intraperitoneal chemotherapy—The challenges of bringing chemotherapy into surgery

AORN Journal, Dec, 2004 by Patricia Foltz, Cheryl Wavrin, Robert Sticca

Cancer treatment typically includes radiation, chemotherapy, bone marrow transplantation, and surgical removal of cancerous infiltrates with adjuvant chemotherapy and/or radiation therapy. Perioperative nurses at Altru Health System, Grand Forks, ND, embraced a new challenge of combining chemotherapy with a surgical procedure. The procedure, heated intraoperative intraperitoneal chemotherapy (HIIC), also known as hyperthermic intraperitoneal chemotherapy, intraperitoneal chemohyperthermia, and continuous hyperthermic peritoneal perfusion, was introduced at Altru Health System by Robert Sticca, MD. This procedure offers the community a different treatment option for intraperitoneal carcinomatosis.

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Heated intraoperative intraperitoneal chemotherapy allows surgeons to treat microscopic residual disease after performing macroscopic cytoreductive surgery. (1) This offers a chance for a cure in select patients. (2) The benefits of HIIC include the following.

* Chemotherapy treatment is accomplished in one session rather than in repeated sessions.

* Direct contact of a higher concentration of chemotherapy with cancer cells (ie, 75 to 100 times greater concentration) is achieved than with systemic chemotherapy treatment.

* Heat itself kills cancer cells.

* Heat improves penetration of chemotherapeutic agents into remaining cancer cells after surgical debulking.

* High concentration chemotherapy is administered while the patient is anesthetized, which prevents the side effects of nausea and vomiting.

HISTORY

Heated intraoperative intraperitoneal chemotherapy was pioneered at the Washington Cancer Center, Washington, DC, by Paul Sugarbaker, MD in the early 1980s. Cancer cells are more sensitive to heat than normal cells, so using heat improves cancer kill rates. Dr Sugarbaker combined chemotherapy with heat and discovered that heat potentiated the effectiveness of chemotherapy.

Dr Sticca performed the first HIIC procedure at Altru Health System on Aug 15, 2003. He since has performed six more HIIC procedures, and all the patients are still alive without evidence of intraperitoneal reoccurrence. Approximately 25 to 30 facilities throughout the United States and multiple institutions in Europe currently are performing this procedure.

INDICATIONS FOR SURGERY

Intraperitoneal carcinomatosis is cancer that has spread throughout the peritoneal cavity. It generally is a cancer that originates from the gastrointestinal tract (ie, colon, gastric), although almost any tumor can metastasize to and spread through the peritoneal cavity. Candidates for HIIC have intraperitoneal carcinomatosis but do not have distant metastasis or liver cancer. Absolute indications for HIIC are pseudomyxoma peritonei and malignant peritoneal mesothelioma. These rare diseases represent approximately 1,000 to 2,000 of the cancer cases in the United States annually. (2-4) Unofficial applications of HIIC include treating colorectal, gastric, and ovarian cancer, and ongoing research indicates significant survival benefits. (2-4) Patients with these types of cancers may undergo this procedure; however, distant metastases disqualify them as surgical candidates. (2-4)

Patients must be otherwise in relatively good health because the procedure is lengthy and extensive.

Hyperthermic intraoperative intraperitoneal chemotherapy is administered after a major abdominal procedure and may be accompanied by massive fluid shifts, moderate blood loss, plasma electrolyte changes, and changes in coagulation parameters (1)(p4)

OVERVIEW OF THE SURGICAL PROCEDURE

The goal of the HIIC surgical procedure is to remove as much visible cancer as possible, leaving tumors no larger than 2 mm. Heated intraperitoneal intraoperative chemotherapy is most effective for tumors less than 2 mm based on experimental evidence that has shown that heated chemotherapy will penetrate up to 2 mm in depth, thereby eradicating tumors smaller than 2 mm in size. Leaving tumors that are larger than 2 mm lessens the chance for cancer elimination. This portion of the surgical procedure is known as debulking or cytoreductive surgery (Figure 1). Debulking can take eight to 12 hours, depending on the extent of the cancer and the number of tumors.

[FIGURE 1 OMITTED]

The HIIC portion of the procedure can be performed using an open or closed approach. The open, or coliseum, technique requires manual distribution of the chemotherapeutic solution on the peritoneal surfaces. This can result in aerosolization of the chemotherapy solution, which increases perioperative staff members' potential for direct contact with the chemotherapeutic solution. The closed technique is performed by inserting catheters into the patient's abdomen after the debulking procedure, temporarily closing the patient's abdomen, and then circulating the chemotherapeutic solution through the patient's abdomen via the catheters. This eliminates the risk of aerosolization and direct contact with staff members. For safety reasons, at Altru Health System, HIIC is performed using the closed approach.

Health Care Industry

Heated intraoperative intraperitoneal chemotherapy—The challenges of bringing chemotherapy into surgery

AORN Journal, Dec, 2004 by Patricia Foltz, Cheryl Wavrin, Robert Sticca

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