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New Armaterium in Cancer Treatment

Traditionally gastrointestinal cancer which had spread to the abdominal cavity lining (i.e Peritoneum) were treated with a nihilistic attitude and were considered stage 4. Their treatment has been like those of other metastatic solid tumours which include Intravenous chemotherapy. Treatment with IV chemotherapy for such patients with has yielded poor results with median survival being 6 to 9 months in the last decade and newer multi-modality chemotherapeutic regimens have at the most improved survival to the tune of 12 to 15 months.

So, does this principle of One shoe fit all for treating patients with cancer of the abdominal lining on lines of other metastatic solid cancers right? Or time has come to think of a tailormade solution for this group of disease.
Sanjivani Cancer Care

Similar to Solid organ Metastasis ??

Sanjivani Cancer Care

Plasma Peritoneal Barrier

We all know the abdominal lining has different physiology when compared to other solid organs in the body which harbour metastatic cancer cells. The main difference is in their blood supply. In solid organs where blood supply is rich and can attain higher concentration of chemotherapeutic drugs on other hand the abdominal lining has got a plasma peritoneal barrier which restricts the diffusion of drugs across the barrier resulting in a lower concentration of drugs at these sites leading to poor results.

To overcome this plasma and the abdominal lining barrier came the concept of Intra peritoneal chemotherapy where the chemotherapy solution is directly given inside the abdomen at the time of surgery or after surgery. The chemotherapy cells act on the microscopic cancer cells present on the abdominal lining and killing them effectively while the plasma – peritoneal barrier prevents absorption of drug into the circulation reducing the side effects of the drug as compared to conventional intravenous chemotherapy. This gives us an advantage to use large doses of chemotherapy inside the abdominal cavity with less chances of complications.

Adding Heat to the chemotherapy solution enhances the killing power of the drug and increases potency of the treatment. During this novel technique of Heated intraperitoneal chemotherapy (HIPEC) we circulate chemotherapy at a temperature of 43 degrees for a period of 60 to 90 minutes.

Sanjivani Cancer Care
Sanjivani Cancer Care

Currently HIPEC can be used for the following conditions:

  • Pseudomyxoma Peritonei
  • Appendix Cancer
  • Selected cases of Colorectal cancers
  • Mesothelioma
  • Advanced Ovarian cancers
  • Selected cases of Stomach cancers

A recently published article in the New England Journal of medicine has shown benefit of adding HIPEC to standard treatment of stage 3 Ovarian cancers at the time of cyto reductive surgery which increase the overall survival by 12 months. Similarly, many studies in peritoneal cancers of Colorectal origin have shown improvement in overall survival with HIPEC as compared to the standard intravenous chemotherapy.

Hyperthermic Intraoperative Chemotherapy (HIPEC) is always combined with cytoreductive surgery where first all the seen disease in the abdomen is removed through an open incision or through a key hole technique in feasible patients with low disease load. After complete disease removal the heated chemotherapy is circulated in the abdomen at a temp of 43 degrees for a period of 60 to 90 minutes. The idea behind this approach is that all visible tumour is removed and any small, microscopic residual disease which is not seen by the eyes is taken care by the circulating chemotherapy in the abdomen. Another form of Intra peritoneal chemotherapy is Piped aerosol form which is called as PIPEC and used for those patients who have unresectable peritoneal disease in the abdomen and the chemotherapy is given to either control the growth of the disease or reduce the volume of the disease.

Current Scenario of HIPEC in India :

Currently the treatment of HIPEC is available in few select centres across India concentrated in the Metro cities of Mumbai, Delhi, Bangalore, and Chennai. HCG Manavata is the first centre in the whole of Northern Maharashtra to introduce this novel treatment at a very affordable cost. The cost of such treatment in metro cities range between 7 to 15 lakh rupees while, HCG Manavata is being able to offer this cutting-edge treatment at around 5 lakh rupees. HCG has the latest equipment of Belmont hyperthermia machine manufactured in United States of America which can give accurate temperatures of 43 degrees at the time of chemotherapy circulation for an effective therapy.

Dr. Manke was trained in HIPEC at the Christie NHS foundation trust at Manchester for a year which is one of the only two referral centres in the UK doing HIPEC. Dr. Aditya Manke has an extensive experience of dealing with such advanced cases.


CRS is short for cytoreductive surgery. It is simply the removal of all sites of cancer within the abdominal cavity. However, the operation itself is not simple and should only be performed by experts with many years of experience.
CRS is very different from standard operations for abdominal cancer. In most instances, patients with peritoneal carcinomatosis (disease that has spread in the peritoneal cavity) are not offered operations since these patients are considered to have unresectable disease, that is, cancer that cannot be removed with surgery.

However, CRS has been shown to be effective in carefully selected patients with peritoneal carcinomatosis. The goal of our surgical oncologist at Stony Brook is to remove all visible cancer in the abdominal cavity. Since most surgeons have limited surgical experience with peritoneal carcinomatosis, it is very important to find surgeons with years of experience in this setting.
HIPEC is short for hyperthermic (heated) intra-peritoneal chemotherapy. It is simply the administration of heated chemotherapy solution into the abdominal cavity of patients with peritoneal carcinomatosis.

The heated chemotherapy is delivered into patients while they are in the operating room during the CRS procedure. The heated chemotherapy can be delivered using either the open or closed techniques, when the skin is either sewn closed or left open during the chemotherapy procedure.
CRS and HIPEC work together to eradicate and kill all cancer cells. With CRS, all gross and visible cancer cells are removed. With HIPEC, the remaining microscopic cancer cells are treated. The heat and chemotherapy work in combination to eradicate and kill cancer cells.
HIPEC can be used to treat patients with gastric cancer, colorectal cancer, appendiceal cancer, mesoteliomas, and gynecologic cancers.
Traditional chemotherapy is given through the intravenous route to reach the cancer targets. Unfortunately, the disease in peritoneal carcinomatosis often has poor or limited blood supply; therefore, it is more difficult for intravenous chemotherapy to reach these tumors to kill them. HIPEC allows direct contact between the chemotherapy drugs and microscopic cells that remain in the peritoneal cavity.
 HIPEC is not experimental and studies have verified that it is an effective and safe procedure in experienced medical centers.
There are numerous reports showing that this procedure may be dangerous and risky. With our years of experience, we have performed this procedure safely with zero mortality.
There is no formal curriculum for training in CRS and HIPEC, so patients should seek surgeons trained at high volume HIPEC centres with established track records of performing these complex operations.
 It is clear that many physicians, including surgeons, do not know or understand the CRS and HIPEC procedure. In many instances I see patients who were told by their physicians that they had no options. Any patient with cancer that remains confined to the peritoneal cavity may be a potential candidate for CRS and HIPEC.

Schedule an appointment with Dr. Manke to find out if your patient is a suitable for HIPEC or not.
 Most of our patients have a hospital stay of approximately 7-10 days. In some cases, the hospitalization could be shorter or possibly longer. For all of our patients, our expectation is that they will return home after surgery being able to complete their normal daily home activities.