By Dr Kapil Kumar
A 65-year-old hypertensive lady with Carcinoma Ovary post three cycles of chemotherapy was admitted to BLK Cancer Centre. Carcinoma is a type of cancer in the epithelial cells of the abdominal cavity. Cancer in each of the abdominal organs can spread to abdominal surfaces and the peritoneum. This kind of spread is called peritoneal carcinomatosis and traditionally, considered an incurable disease with a life expectancy of not more than few months. Despite undergoing chemotherapy, her disease was present with nearly two liters of ascites(abnormal accumulation of fluids in the abdomen) and thickened omentum and peritoneum which are the fatty lining covering stomach, large intestines and other abdominal organs containing lymph nodes.
A specialized oncological team took up the task which was led by Dr Kapil Kumar, Director & HOD, Surgical Oncology. On complete and detailed investigation it was observed that the carcinoma involving the peritoneum, included metastasis (spread) of cancer of the appendix, cancer of the colon and rectum, cancer of the ovaries, and cancer of the stomach. After going through the complete history of the patient, the team came to a conclusion of performing multiple surgeries, using the innovative technique known as Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
What is a CRS?
Because heated chemotherapy can penetrate only at a very limited distance in the tumor tissue, it is imperative to remove all visible and palpable tumor deposits before HIPEC is delivered. Surgery for removal of tumor deposits in the abdomen is known as cytoreductive surgery. Cytoreductive surgery is a complex surgical procedure, during which some organs are resected (removed). This includes various surgeries as in the case of this patient. She underwent the following: –
1. Total Abdominal Hysterectomy(TAH) – It is a surgical procedure done for the removal of uterus along with cervix. It is done in extreme cases like cancer when non-surgical treatments fail.
2. Bilateral Saplingo Oopherectomy(BSO) – This surgical procedure is done for removal of both ovaries and the fallopian tube. It is usually performed along with TAH when the cancer cells have spread completely and a more casual term is used ‘Ovariohysterectomy(TAH-BSO)
3. Lymphadenectomy – lymph node dissection is the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer. This patient also underwent pelvic and para aortic lymph node dissection.
4. Omentectomy – Surgery to remove part or all of the omentum, an large apron of fatty tissue containing veins, arteries, lymphatics. The omentum attaches to and nourishes the stomach and the entire colon.
5. Peritonectomy is the most common surgical procedure for peritoneal mesothelioma patients. The goal of the surgery is to remove the cancerous part of the lining of the abdominal cavity.
6. Extended Right Hemicolectomy – Open right hemicolectomy is a procedure that involves removing the cecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first one-third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes.
With more than 11 hours of complex surgical performance the patient was now ready for HIPEC. This type of complex surgery requires special equipments and high surgical skills. CRS is aggressive removal of all or most visible tumours in the abdomen and preventing growth of microscopic cells which are left behind. After completion of the resection of all tumor tissue, the HIPEC procedure was performed.
How is the HIPEC Procedure conducted?
Hyperthermic Intraperitoneal Chemotherpy (HIPEC) is instilled via a machine which circulates Chemotherapy solution in the peritoneal cavity at 42 degree Celsius for 60-90 minutes. During the HIPEC procedure, a machine will continuously circulate a heated sterile solution containing a chemotherapeutic agent throughout the peritoneal cavity of the patient, for one to one and half hours and killed the remaining cancer cells. The HIPEC procedure also improves drug absorption and effect with minimal exposure to the rest of the body. In this way, the normal side effects of chemotherapy can be avoided. It is being performed in selected centres across India including BLK Cancer Centre and abroad.
She made steady post-operative progress, and was discharged after two weeks. She is now undergoing her remaining chemotherapy procedure. Her quality of life has improved and chances of her survival are very much on the cards.
Most commonly treated diseases are pseudomyxoma peritonei, mesothelioma, colon and rectal cancer, appendiceal cancer, gastric cancer, ovarian cancer, and primary peritoneal cancer.
Another 43 years old African patient was diagnosed with carcinoma ovary with incomplete staging surgery done in Kenya came to BLK. Where similar procedure was followed with three cycles of chemotherapy and CRS was done. The team drained out 19 liters of ascites. She is making steady progress now and has hope of improved survival despite stage IV Ovarian Cancer.
The HIPEC procedure, when combined with CRS, has proven to be an effective therapy that has improved survival outcomes. BLK Cancer centre has now treated many peritoneal cancer patients in the recent times with this innovative technology.
Dr Kapil Kumar, & HOD, Surgical Oncology, BLK Cancer Centre, New Delhi