Hot Chemotherapy 
(HIPEC)

Hot chemotherapy is the application of a heated chemotherapy solution to the abdominal cavity of the patient in cancer types which spread on the abdominal membrane cavity. Heated chemotherapy solution is applied to the patient’s abdominal cavity after cytoreductive surgery. Successful results are received in certain types of the cancer with hot chemotherapy. Hot chemotherapy (HIPEC) is applied together with cytoreductive surgery. Some of the cancer types for which successful results have been taken with cytoreductive surgery and hoy chemotherapy:

• Appendix Cancers (Appendix mucinous adenocarcinoma) 

• Peritoneal Mesothelioma (internal membrane)

• Colorectal Cancers (Colon/small intestine cancers)

• Ovarian Cancer
• Neuroendocrine Tumors

• Gastric Cancer 
•
Other cancers associated with the digestive system
 
These cancer types sometimes spread to the abdominal wall and other organs. In these situations, neither surgery or chemotherapy can be effective alone. Hot chemotherapy to be applied with cytoreductive surgery is a new and effective treatment approach for these cancer types which are difficult to be treated. The first step in cytoreductive surgery/hot chemotherapy is the removal of all visible cancerous materials from the body. (Cytoreductive surgery aims to reduce the number of cancer cells in the body).

 

Cytoreductive Surgery

The surgical approach to advanced ovarian, primary peritoneal cancer, colon cancer, and gastric cancer has improved from tumor removal to more comprehensive surgical procedures. The aim of this surgery is to remove all visible tumors affecting the protective membrane of the abdomen. Cytoreductive surgery is a complicated process, it may take quite a long time and only an experienced specialist can perform this procedure effectively.

In cytoreductive surgery, the surgeon removes tumors using an electrosurgical tool called as the handpiece. This tool burns the diseased tissue with excess heat produced using high-voltage electricity. These complicated procedures, which require removal from many organs, usually last for a long time and should be applied by a surgeon who has extensive knowledge about the anatomy of the abdomen.

 

Hot Chemotherapy

Once the whole visible cancer has been removed, the surrounding organs are irrigated with a high-concentration chemotherapy drug, which is heated and applied for only one time during the operation. Studies have shown that this particular type of chemotherapy is effective against microscopic cancer that cannot be removed by cytoreductive surgery. This approach can eliminate the need for a long and challenging traditional chemotherapy process in some patients.

Are You Suitable for Hot Chemotherapy?

The most suitable candidates for hot hemotherapy are the ones who have one of the diagnoses below:

• Appendix cancer

• Colon cancer 

• Desmoplastic small round cell tumors (usually seen in adolescents and young adults) 

• Malignant ascites 

• Mesothelioma (internal membrane tumor) 

• Ovarian cancer 

• Abdominal membrane cancer 

• Gastric cancer 

• Other advanced cancers in the abdominal area

Hot chemotherapy is a long-term treatment for abdominal cancers in some patients. In other cases, hot chemotherapy allows doctors to treat untreatable cancers as if they were chronic diseases rather than fatal diseases. Hot chemotherapy is not suitable in the following cases:
Treatment is definitely appropriate in the following situations: 

• ECOG performance status is greater than 2 

• Cancers which are not seen to be possible to be surgically removed by imaging

• Cancers spreading out of the abdominal area 

• Concomitant diseases that prevent extensive surgeries (renal failure, heart disease, COLD and others) 
• PCI Index (intra-abdominal spread scoring is too high) 

 

What Should You Expect?

Hot chemotherapy has a lot of benefits for the advanced abdominal area cancers:

• Less side effect

• Increase in life quality

• The rest of the body is exposed to minimum chemotherapy 

• The cancer-killing effect of a chemotherapy drug is increased

• IT MAY EXTEND THE EXPECTED SURVIVAL TIME!

 

Hot Chemotherapy Procedure

Although there may be a certain level of change depending on the doctor and treatment center, the general concept of operation is always the same. The procedure has two phases: Surgical intervention and hot chemotherapy bath.

 

• Stage: Surgery

Firstly, the tumor is removed from the body with cytoreductive surgery as much as possible. The procedure may include a wide variety of surgical techniques which aim to clear abdominal cavity from all visible aspects of cancer. Hot chemotherapy is not effective when applied without surgery, because chemotherapy drugs can not reach the depth of tumors. Cytoreductive surgery is a very challenging procedure for the surgeon, because cancer can be combined and may constitute thousands of small tumors covering the whole abdominal membrane. In some cases, it may not be possible to clean the whole tumor and you may need to consider other treatment options.

 

• Stage: Chemotherapy Bath

Even if the surgeon removes all visible tumors, microscopic cancer cells will definitely remain. These cells cause a serious risk for the return of cancer. For this reason, these cells are targeted with heated chemotherapy drugs immediately after the surgery. The aim is to extend the life expectancy by diminishing as much cancer cells as possible which cannot be destroyed by surgery. Immediately after the surgical procedure is finished, plastic tubes called catheters are placed in the abdominal cavity. Then, tubes are connected to the perfusion system (an advanced machine that warms up the chemotherapy solution, pumps and collects back this solution)
In addition, special probes are placed which allow following the temperature of the solution in the body. After all tubes and probes are placed, the incision is closed with suturation threads or skin staples. Then, the perfusion system is operated. Perfusion system starts continually giving the salt solution into the abdominal cavity and collecting it back. The solution is increased to the desired temperature (between 10.5 and 43 degrees) while passing through the machine. Cancer cells begin to die at 40 degrees; normal cells can endure until 44 degrees. When the solution reaches the correct temperature, one or more chemotherapy drug is added in the solution. While the drug is mixed with the solution and fills the abdominal cavity, the doctor applies massages on the patient’s abdomen with his hand. This provides a solution to be mixed completely and helps cancer-killing drugs to reach every tissue surface where microscopic cancer cells may be present. Chemotherapy drugs are circulated between the patient’s abdominal cavity and the machine for a certain time. Although 2 hours of applications can be seen in some studies, doctors usually do not perform this procedure for more than 1 hour. After chemotherapy bath is completed, the drug solution is taken out of the body. Then, the abdominal cavity is irrigated with non-drug salt solution. Finally, the surgeon opens the incision again, removes tubes and probes and then closes the incision for the last time. The procedure including cytoreductive surgery and hot chemotherapy may last for 6 hours – 18 hours (since the duration of surgical procedure changes for each situation). The more the cancer is spread into the abdomen, the longer the operation lasts for.

 

After Procedure

Following the hot chemotherapy operation, hospitalization period is for 10-12 days. Fatigue is seen commonly after the operation, but it is important to stay active in order to prevent complications such as clotting. The recovery period after the operation may last for a few months. Your surgeon will inform you about the recovery period including how to care the incisions. The most compelling part of the recovery period is fatigue. It possibly takes 2-3 months for you to feel normal. It is important to stay active (within your own limits) and have balanced nutrition during this period. You should stand up and have a walk during the recovery period. Try to do more every other day.
Frequently Asked Questions about Hot Chemotherapy

 

Sıcak Kemoterapi ile ilgili Sıkça Sorulan Sorular

What is hot chemotherapy?

Hot chemotherapy is the administration of a heated chemotherapy solution into the patient’s abdominal cavity if the cancer is spread into the abdominal cavity. Heated chemotherapy solution is given into the patient’s abdominal cavity after cytoreductive surgery.

Who are appropriate for hot chemotherapy?

The most appropriate people for hot chemotherapy are those whose cancers are restricted withinthe abdominal area. Some of these cancers are pseudomyxoma peritoneum, colon cancer, appendicitis cancer, gastric cancer, ovarian cancer and primary abdominal membrane cancer. On the other hand, other types of cancer may benefit from this treatment. You should talk to your surgeon if you are a good candidate for this operation.

How does hot chemotherapy function?

Hot chemotherapy consists of two steps. At the first step, cytoreductive surgery is performed. The surgeon makes an incision on the abdomen for cytoreductive surgery and cleans the visible tumors as much as possible. At the second step, tubes which connect the patient’s abdomen to a perfusion machine are placed in the abdominal cavity. Machine continuously pumps the heated solution into the abdominal cavity via these tubes and collects it back. Chemotherapy drugs are added to this solution as in two dosages within a period of 90 minutes. Chemotherapy solution discharges into the abdominal cavity, turns back to the machine; it is heated again and goes back to the abdominal cavity. During this procedure, the surgeon kindly applies massage on the patient’s abdomen and ensures the chemotherapy solution to reach all organs in the abdomen. At the end of therapy, a chemotherapy solution is taken out of the abdomen and abdominal cavity is irrigated with the salt solution.

What are the advantages of hot chemotherapy?

• In hot chemotherapy, a higher dose of chemotherapy is applied in order to control the extension of cancer into the abdomen.

• Temperature makes the cancer cells more sensitive to chemotherapy.

• Hot chemotherapy enables a more focused treatment: cancer in the abdominal area is irrigated with chemotherapy drugs.

What is cytoreductive surgery?

Cytoreductive surgery is the procedure of removing all visible tumors in the abdominal cavity. It is a challenging operation and can only be performed by specialists who have long years of experience.

What is the difference between cytoreductive surgery and normal surgery which is applied for the cancer of the abdominal area?

Cytoreductive surgery is quite different from standard operations which are applied for the cancers in the abdominal area. In many cases, the operation is not recommended for patients whose cancer is spread into the abdominal membrane cavity, because cancer of these patients cannot be destroyed by the operation. However, cytoreductive surgery has been shown to be effective in carefully chosen patients experiencing this situation. The role of the surgeon is to clean the whole visible cancer in the abdominal cavity. Since most of surgeons have restricted experience in this cancer type, it is very important to find a surgeon who has long years of experience in this field.

Why should you prefer hot chemotherapy instead of traditional chemotherapy?

Traditional chemotherapy is applied by vein in order to reach to the target cancer. Unfortunately, blood circulation is restricted in cancer cases which have spread into abdominal membrane cavity. For this reason, it is more difficult for chemotherapy drugs to be given by veins to reach these tumors and kill them. Hot chemotherapy provides direct contact of microscopic cells in abdominal membrane cavity with chemotherapy drugs.

SIs hot chemotherapy an experimental application?

Hot chemotherapy is not experimental. It has been proven to be an effective and safe procedure by studies. 

How long is the recovery period?

Hospitalization period is about 10-12 days after hot chemotherapy operation. It may be shorter or longer according to the situation. Patients can resume their daily normal activities after returning back to home.

What Are Side Effects?

Side effects may change from person to person. Some of these possible side effects are:

• Nausea and vomiting 

• Clotting

• Anastomosis leak 

• Increase in infection risk

• Diarrhea
• Fatigue 

• Failure to consume sufficient calorie after the operation

What are the differences between hot chemotherapy and traditional chemotherapy?

Some cancer types are difficult to be treated, especially for the cancers in the abdominal cavity. These cancers cannot be killed by vascular chemotherapy as in the chemotherapy applied thorough abdominal membrane. Hot chemotherapy specialists state that temperature strengthens chemotherapy in order to kill these cancer cells. Hot chemotherapy;

• Enables the administration of a high dose of chemotherapy 

• Densifies and strengthens chemotherapy inside the abdomen 

• Minimizes chemotherapy exposure to the rest parts of the body
• Increases the life expectancy when applied to a suitable patient 

• Increases chemotherapy absorption and the effect of chemotherapy on cancer cells 

• Decreases some side effects of chemotherapy

 

Treatment After Hot Chemotherapy

Although hot chemotherapy procedure is applied to treat the patient, abdominal membrane cancer is an aggressive disease and frequently recurs even after successful hot chemotherapy procedure. The course of disease after hot chemotherapy depends on many factors such as the source of disease and its degree during diagnosis, the possibility of removing whole visible cancer during surgical intervention and patient’s condition. Not all patients recover from cancer after hot chemotherapy, but in general, the patient’s life expectancy is expressed by years, not by months after this procedure. Some patients can get rid of the disease after the procedure. In order to improve the success of hot chemotherapy, the doctor may suggest continuing with systemic chemotherapy after the operation. Systemic chemotherapy application, applied 4-6 weeks after hot chemotherapy procedure, can be made with pills and/or in veins. The aim of this additional chemotherapy is to prevent and delay recurrence of abdominal membrane cancer and the spread of cancer to the organs like the lung. This is called as supplementary chemotherapy. Administration of supplementary chemotherapy after hot chemotherapy is not beneficial for each patient. While deciding for supplementary chemotherapy, many factors about the special condition of the patient should be considered. The patient may encounter certain problems years after hot chemotherapy. Patients may have something to ask. For this reason, it is important that an experienced doctor in abdominal membrane cancer and hot chemotherapy closely follows the patient in this period. Results of hot chemotherapy may significantly change between patients. Results to be obtained change depending on the source of abdominal membrane cancer and how much it progresses at the time of diagnosis. In general, satisfactory results are gained after hot chemotherapy in pseudomyxoma peritoneum patients from which tumors have been successfully removed. In the majority of these patients, there is no possibility that disease completely disappears. It is rarer that disease completely disappears in patients who have colon cancer or malignant internal membrane tumor. But in general, after hot chemotherapy, the life expectancy of these patients are expressed by years rather than by months.

Treatment After Hot Chemotherapy
What Are The Benefits of Hot Chemotherapy 
Hot chemotherapy has a lot of benefits compared to standard chemotherapy:

• Hot chemotherapy is usually a one-time application. On the other hand, standard chemotherapy requires a number of chemotherapy sessions performed over the weeks or months. Standard chemotherapy, when carried out over a long period of time, may increase the patient’s costs and may cause the patient to stay out of his / her job more, as it requires repeated visits to the doctor.

• In hot chemotherapy, chemotherapy drugs are administered directly to the abdominal cavity. This minimizes the risk of poisoning, because drugs do not circulate in the whole body’s circulatory system. More importantly, any side effects are much shorter than those of standard chemotherapy because the abdominal cavity is irrigated with a salt solution after the drugs are withdrawn. In standard oral or intravenous chemotherapy, chemotherapy drugs spread into all parts of the body and cause many negative effects.

•Hot chemotherapy is a more focused treatment and directly applied to a certain type of cancer in patient. Because the treatment is much more focused, much higher doses of chemotherapy drugs can be used. When chemotherapy is administered in this way, the probability of death of the remaining cancer cells is much higher than that of standard chemotherapy.

• Heating of chemotherapy drugs can kill cancer cells much more effectively than conventional chemotherapy.

• Although hot chemotherapy is a relatively new treatment approach, recent studies have shown that approximately 25% of patients diagnosed in the early stages of mesothelioma can get rid of cancer. When compared to standard chemotherapy, where disease can be rarely overcome, hot chemotherapy is a very significant development in terms of these statistics. 

• Many studies have shown that hot chemotherapy increases the life expectancy in carefully chosen cancer patients. Studies also suggest that hot chemotherapy combined with cytoreductive surgery may be more effective and beneficial than chemotherapy or surgery alone.

• After hot chemotherapy applied together with cytoreductive surgery, life quality significantly increases. Long-term side effects are minimal. Patients can return to their daily activities after the recovery period and the post-operative healing process is much faster than in conventional surgeries.

•This operation can clean the whole visible cancer without causing such complications as fluid accumulation or/and intestinal congestion.

Side Effects
Side Effects 
Although most of the side effects are caused by operation rather than directly caused by chemotherapy. The operation has serious complications which are stated in the literature and seen to be around 30%. Since an experienced surgeon working with a qualified medical team will decrease the complication risk, it is very important to choose the correct surgeon for the operation. Possible side effects associated with the operation are:

• Pancreas inflammation (6-7%)

• Post-operational bleeding or leakage from intestines because of tissue damage (4-5%)

• Infection and bleeding risk depending on a smaller number of leucocytes in the blood (%10)

Some of the side effects related to chemotherapy drugs:

• Nausea and vomiting: The severity of this side effect varies from person to person. If necessary, nausea medicine will be given to the patient. After the operation, you will have a tube that passes through your nose and reaches your stomach. This tube helps prevent nausea (but may cause discomfort).

• Infection susceptibility: Since chemotherapy will be applied to your abdomen, infection risk will increase in the abdominal area. Even if no chemotherapy to be applied, there will be an infection risk. However, chemotherapy increases this risk.
• Retardation of recovery: Chemotherapy may slow down recovery period in the abdominal area after the operation. 

• Fatigue:  Chemotherapy may make you feel tired and unenergetic. When this is combined with a big operation, you need much time to have rest and go back to a normal energy level.
• Diarrhea: This may cause a problem. However, the reason causing diarrhea is the operation itself rather than chemotherapy.  
• Mouth wounds: Wounds can be seen in mouth after the procedure. However, this is a low possibility. Talk to your doctor if you have such problems. You may need to have mouth gargle. 
All side effects listed here are possible side effects. You may not have any of these effects. Most of the chemotherapy drugs stay in the abdomen rather than transfusing into the blood. For this reason, most of the possible side effects (increase in infection risk and retardation of the recovery process) will be related to the abdomen.