Advanced Strategies for Selecting Patients for HIPEC in Peritoneal Metastases

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• Imaging Limitations for Peritoneal Cancer
• Role of Exploratory Surgery in Diagnosis
• Preventing Peritoneal Metastases
• Matching Patients to the Right Treatment
• Future of Patient Selection Criteria
• Full Transcript

Imaging Limitations for Peritoneal Cancer

Dr. Paul Sugarbaker, MD, emphasizes a significant challenge in treating peritoneal surface malignancies. Modern radiologic technology, including MRI, CT, and PET CT scans, is highly inaccurate for detecting low-volume cancer. These imaging modalities have a size threshold for identifying peritoneal metastases of about 1 to 1.5 centimeters. A patient can have up to a thousand small cancer nodules spread throughout the abdominal cavity, and these advanced scans can still appear completely normal.

This diagnostic gap was illustrated by Dr. Sugarbaker's experience with an ovarian cancer patient. Her CT, PET CT, and MRI scans were all normal. However, during surgery, several hundred small cancer metastases were discovered throughout her peritoneal space. This case underscores why imaging alone is insufficient for staging peritoneal carcinomatosis accurately.

Role of Exploratory Surgery in Diagnosis

Because imaging is unreliable for small metastases, surgeons often must rely on direct visualization. Dr. Paul Sugarbaker, MD, states that an exploratory laparotomy or diagnostic laparoscopy is sometimes necessary to see the true extent of peritoneal involvement. This surgical exploration provides a definitive assessment that imaging cannot match.

Dr. Anton Titov, MD, notes that this approach is used when there are doubts about a patient's candidacy for major surgery. A laparoscopic exploration helps determine if a patient will benefit from the full cytoreductive surgery and HIPEC procedure. This step is crucial to avoid subjecting patients to a major operation with a low likelihood of success.

Preventing Peritoneal Metastases

A proactive approach to patient selection involves identifying individuals at high risk for future peritoneal spread. Dr. Paul Sugarbaker, MD, highlights that it is possible to prevent peritoneal metastases by treating patients correctly at the time of their initial cancer surgery. This is particularly relevant for cancers of the colon, stomach, and ovaries that are known to spread within the abdominal cavity.

Preventive strategies can be implemented during the primary resection of a colon or gastric cancer. This forward-thinking method represents a shift towards intercepting the disease process before widespread metastases occur, potentially improving long-term survival rates for these high-risk patients.

Matching Patients to the Right Treatment

The core principle of patient selection is ensuring the right treatment is matched to the right patient. Dr. Paul Sugarbaker, MD, explains that the goal is to avoid performing a massive cytoreductive surgery on a patient who has little chance of benefiting from it. With many variants of treatment for metastatic gastrointestinal cancer, precision in selection is paramount.

This matching process is complex and not yet perfected. It requires a careful evaluation of the disease's extent, the patient's overall health, and the potential for a complete cytoreduction. The decision to proceed with HIPEC is a calculated one, based on the best available information, which often includes surgical exploration.

Future of Patient Selection Criteria

Dr. Paul Sugarbaker, MD, indicates that the methodology for selecting patients will continue to evolve. The ability to identify high-risk patients preemptively is an area of amazing progress. As knowledge grows, the criteria for who should receive cytoreductive surgery and HIPEC will become more refined and effective.

Improving selection criteria will maximize the benefit of this aggressive treatment strategy. The future lies in better predictive models and perhaps enhanced imaging techniques that can finally detect those elusive sub-centimeter peritoneal metastases without invasive surgery.

Full Transcript

Dr. Anton Titov, MD: Renowned Harvard-trained American cancer surgeon explains how he selects patients for metastatic stage 4 peritoneal cancer treatment. Patient selection is crucial for long-term success of cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to treat metastatic colon cancer, ovarian cancer, or gastric cancers that spread into the abdominal cavity.

Peritoneal metastatic cancer patient selection for treatment. MRI, CT, and PET CT are not accurate for low-volume peritoneal cancer detection.

Dr. Paul Sugarbaker, MD: Exploratory laparotomy helps to identify the extent of peritoneal cancer metastases. There could be 1000 small metastases from ovarian cancer in the peritoneum. CT or MRI will not detect them.

We can prevent peritoneal cancer metastases by treating cancer patients correctly at the time of their primary colon cancer, gastric cancer, or ovarian cancer resection. Colon cancer, gastric cancer, and ovarian cancer spread in the abdomen and peritoneal cavity.

Peritoneal metastases in advanced stage 4 colon cancer treatment by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC), or hot chemo bath with heated chemotherapy.

Dr. Anton Titov, MD: Medical second opinion clarifies colon cancer or ovarian cancer diagnosis. Medical second opinion confirms that cure is possible in metastatic colon cancer.

Intraperitoneal chemotherapy treatment for advanced stage 4 cancer with metastatic lesions in the abdomen.

Dr. Paul Sugarbaker, MD: Medical second opinion helps to select a precision medicine treatment for stage 4 ovarian cancer, stage 4 colon cancer, or metastatic stage 4 gastric cancer.

Get medical second opinion on advanced cancer with peritoneal metastases. Best peritoneal metastatic advanced cancer treatment is by surgical operation and regional chemotherapy.

Video interview with Dr. Paul Sugarbaker, leading expert in peritoneal metastatic cancer treatment, cytoreductive surgery, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC), or hot chemo bath with heated chemotherapy.

Dr. Anton Titov, MD: Patient selection for peritoneal cancer metastases treatment from colon cancer, ovarian cancer, and gastric cancer. Correct selection of patients is very important for successful peritoneal metastatic cancer treatment.

It is important to match a given patient and a given treatment because there are many variants of metastatic gastrointestinal cancer treatment methods, such as cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy, or HIPEC.

How do you select appropriate patients for the Sugarbaker Procedure? How do you choose to treat peritoneal metastatic disease that spreads from cancers in the abdomen?

How do you make sure that you match the right patients with the right extent of peritoneal cancer treatment procedures?

Dr. Paul Sugarbaker, MD: We don't do it very well. There is a lot of work that needs to be done. We have to make certain that a patient with peritoneal metastatic cancer does not get a big operation and have a very low likelihood to benefit from surgery.

It may surprise you that the most modern radiologic technology, MRI, CT, and PET CT, are very inaccurate for low-volume cancer, meaning cancer with small-size but numerous metastases.

I recently had an ovarian cancer patient who had a normal CT of the abdomen, a normal PET CT, and a normal MRI. We found several hundred small cancer metastases spread around her abdominal peritoneal space.

We would not have operated on her unless she had had a small cancer metastatic nodule at one of the port sites from her laparoscopic ovarian cancer procedure.

Unfortunately, we have to operate sometimes without complete knowledge about what's going to happen during the surgical operation.

Perhaps one development in peritoneal metastatic cancer treatment that gave us some help is laparoscopy. Sometimes we have doubts as to whether the patient with peritoneal metastases from gastrointestinal or ovarian cancer is a good candidate for cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Dr. Anton Titov, MD: Then we will do exploratory laparoscopy on these peritoneal cancer patients to determine if cytoreductive surgery and HIPEC will help them or not.

But determining accurately who is the best patient for cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a problem now.

There is another aspect of patient selection that will become increasingly important in the future.

Dr. Paul Sugarbaker, MD: We are able now to identify cancer patients, such as those with colon cancer, ovarian cancer, or gastric cancer, who will be at high risk for the development of peritoneal metastases in the future.

Dr. Anton Titov, MD: We can prevent peritoneal cancer metastases by treating them correctly at the time of their primary colon cancer resection. Or by treating gastric cancer patients preventively for peritoneal metastases at the time of primary gastric cancer operation.

There is amazing progress in imaging technology, such as MRI or PET CT, to evaluate patients with metastatic cancer. But sometimes you have to use the classic surgical technique of exploratory laparoscopy and laparotomy in order to see what is going on in the patient's abdomen and peritoneum.

Dr. Paul Sugarbaker, MD: Yes, sometimes we really have to go to exploratory laparotomy to see the extent of peritoneal involvement by metastatic cancer, such as colon cancer, ovarian cancer, or gastric cancer.

It is not to say that these imaging technologies, MRI, CT, and PET CT, are not accurate or sensitive to discover cancer. CT and MRI can be very sensitive for lung metastases, liver metastases, or for retroperitoneal nodal metastases.

CT, PET CT, and MRI can identify cancer metastases less than 1 cm in size. But the size threshold for peritoneal metastasis is about 1 cm or 1.5 centimeters.

You can have 1,000 of 1 cm or 1.5 cm peritoneal metastases, and the CT, PET CT, and MRI will all be normal, despite a thousand metastases present in the abdomen of such peritoneal metastatic cancer patients.

Dr. Anton Titov, MD: Which patients benefit from peritoneal metastatic cancer treatment by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy? Selection criteria.