R. J. Rivero-Soto1, Z. Hossein-Zadeh1, J. Coleman1, N. Ahuja2, V. Ahuja1 1Sinai Hospital Of Baltimore,General Surgery,Baltimore, MD, USA 2John Hopkins University,General Surgery,Baltimore, MD, USA
Introduction: Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has evolved as the standard of care for patients with peritoneal spread who were considered incurable or untreatable in the past. This is a paradigm shift where combining new technology and directed chemotherapy has rapidly been adopted, along with utilization of risk stratification for improved patient outcomes. Even though CRS and HIPEC are already stablished treatment modalities, more research is necessary to discover the best approach for better outcomes.
Methods: In this study we focus on a review of the current literature being conducted in attend to further revolutionize CRS and HIPEC.To this day, outcomes from CRS and HIPEC procedures are mixed for peritoneal disease which has pushed us to learn from other cancer treatments. For example, we have observed that cancer treatment is rarely given in a one-time, single dose course, as it is done in HIPEC; thus, as part of the future evolution of this method, we are interested in the role of multiple chemotherapeutic agents and immunotherapy in the setting of personalized medicine.
Results: Extensive debulking procedure was initially described for locally advanced ovarian cancer in the 1930s. Subsequent reports by Drs. Griffiths and Munnell in the 1960s reported improved survival for stage IV ovarian cancer in patients with CRS and residual tumor size < 2cm. The next major discovery was the introduction of “thermal transfusion infiltration system” (TIFS) for delivery of hyperthermic intracavitary perfusate by Dr. John S. Spratt. In 1979, the first human was subjected to TIFS; a 35 year old male with recurrent Pseudomixoma peritonei who had previously undergone CRS only.
Further research in the early 1980s focused on the delivery of intraperitoneal chemotherapeutic agents at a concentration 30 times greater than conventional intravenous (IV) dosages. One of the first drugs used was Cisplatin. The rationale of such high doses of intraabdominal chemotherapy was that localized concentrations decreased systemic toxicities. In the 1990s, the Peritoneal Cancer Index (PCI) was developed. In 1995, Dr. Sugarbaker described a stepwise technique for peritonectomy in an attempt to standardize the procedure. In the early 2000s Drs. Glehan and Gilly of France developed the completeness of cytoreduction (CCR) score which allows for documentation of the extent of CRS. CRS was further advanced in 2005 with Sugarbaker introducing greater abdominal exposure with a self-retaining retractor.
Conclusion: This important topic highlights new technologies which allow physicians to view peritoneal malignancies as a more localized disease instead of a disseminated non-treatable condition. CRS with HIPEC is evolving; and future research will allow us to develop a better personalized treatment strategy with better outcomes.