Cytoreduction Surgery and Heated Intraperitoneal Chemotherapy
Offering long-term survival for patients with cancers of the abdominal lining
Diagnosis of cancer that has spread to the abdominal wall lining (peritoneum) is typically considered a lethal diagnosis. But at NewYork-Presbyterian/Columbia University Medical Center, many patients with these advanced cancers can expect long-term survival, thanks to refined surgical approaches and intra-abdominal chemotherapy.
According to Michael Kluger, MD, MPH, Assistant Professor of Surgery, abdominal mesothelioma, colorectal cancer, appendiceal cancer, and ovarian cancer commonly spread from their primary sites to the wall of the abdomen. When they spread, they line the wall of the abdomen with tumor deposits, which cause scarring, inflammation, obstruction of the intestines, and eventually death. Because these cancers typically do not spread outside the abdomen, it is possible to remove the visible tumor deposits (called cytoreduction surgery) and apply chemotherapy to treat any remaining microscopic disease. Research shows that intraperitoneal chemotherapy is highly effective under these circumstances, whereas chemotherapy given through the veins is less effective.
Columbia is one of a few programs in the nation highly experienced in performing complex, extensive cytoreduction surgeries. After removing the visible tumors, the surgeons insert ports for administering chemotherapy, close the abdomen, and infuse a single dose of heated intraperitoneal chemotherapy (HIPEC). After this, the operation is completed.
Without treatment, most patients face a life expectancy of about six months. After cytoreduction surgery and HIPEC, research shows a significant improvement in survival: 40% survival at five years for patients whose cancer spread from the colon; ten years average survival for patients with mucinous appendiceal cancer; and median survival of over 60 months for mesothelioma and ovarian cancer. Systemic chemotherapy is often administered after the operation. “If we decrease the overall burden of disease by removing all visible cancer and the primary lesions, systematic chemotherapy is potentially more effective,” says Dr. Kluger.
Success with this approach largely depends on the experience of the surgeon and program, cautions Dr. Kluger. “With the advent of inexpensive heated intraperitoneal chemotherapy pumps, more centers are beginning to treat patients with peritoneal cancers despite having little, if any, experience. A lot of judgments have to be made during these operations. Removing too much tissue can cause too high a risk of complications. In some cases an operation must be terminated. In other cases, we may have to remove one or more internal organs, and patients have to trust us to make the appropriate decisions during the operation. This is where experience comes into play.”
NYP/Columbia’s mesothelioma program, open since the 1990s, performs more surgeries for peritoneal mesothelioma than any other center in the United States. The outstanding reputation of this program draws patients from all over North America, including many who have been told they could not be treated.
When performing gastrointestinal surgeries, Dr. Kluger collaborates with John Chabot, MD, FACS, Chief of the Division of GI/Endocrine Surgery and Executive Director of the Pancreas Center (and the surgeon who introduced these operative techniques to NYP/Columbia), as well as Robert Taub, MD, PhD, Director of the Mesothelioma Center. For patients with ovarian cancer, Dr. Kluger assists Jason Wright, MD, Levine Family Assistant Professor of Women’s Health (in Obstetrics and Gynecology) and a specialist in gynecologic oncology. Colorectal Division Chief P. Ravi Kiran, MBBS and Steven Lee-Kong, MD, Assistant Professor of Clinical Surgery, provide expertise in cases of colorectal cancer. “Surgeons have to have a lot of comfort working in the abdomen to perform these operations, and our training and collaboration allows that,” says Dr. Kluger.
Not only does the center offer a multidisciplinary team with 20 years of surgical experience, but it also leads in research. Drs. Chabot and Kluger have been following the long-term outcomes of patients with peritoneal mesothelioma. Dr. Taub is conducting research on the penetration of various chemotherapy agents into the abdominal wall. Dr. Lewin is researching novel therapies for ovarian cancer including HIPEC, and Dr. Wright is Principal Investigator of numerous clinical trials in gynecologic cancers.
Dr. Kluger and his colleagues are available to discuss potential referrals by phone or to evaluate any patient who may be a surgical candidate. Full evaluations are performed to rule out distant metastases (spread of cancer to distant organs) and to ensure that patients are strong enough to withstand the effects of major surgery.