Cytoreductive Surgery and HIPEC (CRS-HIPEC) to treat Stage 4 Colon and Rectal Cancers
Dr. Nikhil Agrawal | Last reviewed on
Introduction
The peritoneum is a membrane that lines the inside of the abdomen and covers the abdominal organs. It helps to protect and support the organs and keeps them in place. Peritoneum is important for the immune system, temperature regulation, and the absorption and storage of fluids and nutrients. It has two layers, the inner parietal layer that lines the abdominal cavity and the outer visceral layer that covers the organs. The cancers which affect the peritoneum are called peritoneal cancer.
Peritoneal Cancers
Peritoneal cancers are broadly classified into primary and secondary.
Primary peritoneal cancer refers to cancer that originates in the peritoneum like peritoneal mesothelioma and primary peritoneal cancers. Secondary peritoneal cancer, also known as peritoneal metastasis, refers to cancer that has spread (metastasized) to the peritoneum from another primary cancer site, such as the ovaries, colon, rectum, stomach, appendix, pancreas and gallbladder.
Cancer that spreads to the peritoneum from elsewhere in the body is classified as stage 4. It meant a dismal outcome for the patient. However, with modern treatment, many of these patients have better results.
Colon Cancer and Rectal Cancer with Peritoneal Metastasis
Colon and rectal cancers are among the leading causes of cancer-related deaths worldwide and in India. The peritoneum is the most common site of metastasis from colorectal cancer. These cancers often have a poor prognosis when patients present with advanced disease that has spread beyond the primary tumour to the peritoneum.
The peritoneal disease is usually less responsive to treatment with chemotherapy and targeted therapy due to poor delivery of these drugs to the peritoneum.
Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) offer a potential alternative for some of these patients. By surgically removing as much of the cancerous tissue as possible, CRS can reduce the tumour burden and improve the effectiveness of subsequent chemotherapy. HIPEC involves the delivery of heated chemotherapy directly to the abdominal cavity, which allows for higher drug concentrations and a longer exposure time. This can help to kill any remaining cancer cells.
Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC)
Cytoreductive Surgery (CRS)
Cytoreductive surgery, also known as debulking surgery, is a highly specialised surgical procedure that is often used in combination with HIPEC to treat advanced cases of colorectal cancer that have spread to the peritoneum. The goal of this surgery is to remove as much of the cancerous tissue from the body as possible, to improve the chances of survival and reduce the likelihood of cancer recurrence. The aim is to have no visible cancer after surgery if possible.
Hyperthermic intraperitoneal chemotherapy (HIPEC)
CRS is often performed in combination with hyperthermic intraperitoneal chemotherapy (HIPEC), which involves the heated delivery of chemotherapy drugs directly to the peritoneal cavity. Unlike systemic chemotherapy delivery, HIPEC delivers chemotherapy directly to cancer cells in the abdomen. This allows for higher doses of cancer chemotherapy treatment. Heating the solution also improves the effectiveness of chemotherapy drugs and destroys the microscopic cancer cells that can remain in the abdomen after surgery. The liver detoxifies the absorbed drug and hence there is less toxicity.
Together, these two treatments can help to improve the chances of survival and reduce the likelihood of cancer recurrence in patients with advanced colorectal cancers.
Work up
Before undergoing cytoreductive surgery, patients will typically undergo a thorough evaluation to determine if they are eligible for the procedure. This may include imaging tests, such as CT scans, MRI or PET-CT, to assess the extent of cancer, as well as blood tests and other laboratory tests to evaluate the patient's overall health. Based on the results, your surgeon will determine if cytoreductive surgery is an appropriate treatment option.
Peritoneal carcinomatosis index (PCI)
Peritoneal carcinomatosis index (PCI) is a numerical score that is used to assess the extent of colorectal cancer that has spread to the peritoneum. The PCI score is calculated based on the number and size of tumours that are present in the peritoneum. A higher PCI score shows a greater extent of cancer spread in the peritoneum. The PCI score is typically used to help determine the best treatment options for people with peritoneal cancer. A high PCI score may show that cancer has spread extensively throughout the peritoneum and is more difficult to treat.
Benefits of CRS-HIPEC
Cytoreductive surgery and HIPEC can be an effective treatment for advanced colorectal cancers affecting the peritoneum and can help to improve the chances of survival and reduce the likelihood of cancer recurrence.
In a French trial, CRS-HIPEC in well-selected patients achieved a 5-year survival of 51% compared to 13% in the patients who were treated with standard chemotherapy.
However, the procedure is complex and can have significant side effects, so it is important to carefully weigh the potential benefits and risks.
Another potential benefit of cytoreductive surgery is that it can help to improve the quality of life for patients with advanced cancer. By removing as much of the cancerous tissue as possible, the surgery can help to ease symptoms such as abdominal pain, bloating, and difficulty eating, which can improve the patient's overall comfort and well-being.
Complications of CRS-HIPEC
Despite the potential benefits of CRS and HIPEC, the procedure is not without its challenges. It is a complex and time-consuming surgery that requires a highly trained surgical team and specialised equipment. The most common postoperative complications include anastomotic leaks, bleeding, pulmonary complications, and deep and soft-tissue infections. It is also not suitable for all patients, and careful selection of candidates is necessary to ensure the best possible outcomes.
Summary
In conclusion, CRS and HIPEC is a promising treatment option for colon and rectal cancers that have spread to the abdominal cavity. While it is a complex and specialised procedure, it has been effective in improving overall survival and controlling the disease. Patients with advanced colorectal cancers should discuss this treatment option with their surgeon to determine if it is right for them.
Wish you a speedy recovery!
