A national leader in the specialized care of peritoneal disease, Moffitt Cancer Center is committed to innovation in research and treatment. In this Q&A, Sean Dineen, MD, an associate member of the Department of Gastrointestinal Oncology at Moffitt, shares insight from his extensive experience treating this challenging disease and discusses the benefits of cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC).
What is peritoneal disease?
Dineen: Peritoneal disease describes a pattern of metastatic disease where cancer has spread from where it initially started into the lining of the abdominal cavity. There are some cancers that have a high propensity for this type of spread, including appendix cancers, some types of colon cancers, gastric cancer and ovarian cancer. There are rare cases when cancer starts in the peritoneal lining, and these are typically peritoneal mesothelioma cancers.
What are some of the symptoms and how is the disease diagnosed?
Dineen: One of the challenges with treating these types of cancer is that the symptoms typically present fairly late. They're usually gastrointestinal-related symptoms like abdominal pain and symptoms of obstruction, which are typically nausea, vomiting or bloating.
Most of the time the symptoms aren’t very specific which would ultimately lead to a CT scan where we’ll see some evidence of this. It’s also occasionally diagnosed incidentally. For example, appendix cancer could be diagnosed during what would have been a routine appendectomy. Similarly, we may identify peritoneal disease during surgical procedures for colon and gastric cancers. We would be operating under the assumption that the disease is localized but would see that the disease has spread to the lining or the fat surrounding the organs.
Who is at risk, and is there a way to screen for this type of cancer?
Dineen: Right now, we don’t have a great profile of who is at risk for this overall, but we do tend to see this in younger patients with colon cancer. For appendiceal cancers we don’t have a great sense for what the predisposing factors are. With peritoneal mesothelioma there are some links to asbestos or smoking, but less than for the lung type.
Appendix cancer is quite rare and there's no real screening process for this type of cancer. In colon cancer, which we treat sometimes, it typically would be standard screening colonoscopy. So, if we were able to identify colon cancers earlier, we would see less of this type of advanced spread.
What is your approach to treatment of peritoneal disease?
Dineen: At Moffitt, we assess each patient’s needs to determine the best strategy for treating peritoneal metastasis. We strive to ensure patients are fully informed so that they can make the best treatment decision for their personal health goals. With that in mind, we put a lot of emphasis on educating each patient about the role of surgery, chemotherapy and radiation, including their purposes and potential side effects as well as any possible alternatives.
Most times the treatment options will be a combination of chemotherapy and surgery. We would approach a low-grade appendix cancer differently than a gastric cancer depending on the aggressiveness of the cancer. The more aggressive the cancer, the more likely we are to combine surgery with a regular type of IV chemotherapy. For the less aggressive cancers, surgery alone may be the approach. When we talk about surgery, we're referring to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).
How does the CRS/HIPEC procedure work?
Dineen: For CRS/HIPEC, we investigate all the surfaces of the abdomen and perform what can turn out to be an extensive operation. We take out the lining of the abdominal cavity and then any organs that have tumor on the surface of it. Once we're finished with the cytoreduction, we introduce the heated chemotherapy solution into the abdomen. After about 90 minutes, the solution is rinsed out and incisions are closed. The single chemotherapy treatment helps to treat and sterilize microscopic disease. Altogether, the procedure takes approximately eight to 10 hours to complete.
What are the benefits of HIPEC over traditional chemotherapy?
Dineen: For one, there are fewer side effects. Because the chemo is delivered directly into the abdominal cavity, it is less likely to be absorbed and affect healthy tissues and organs.
In addition, the heated chemotherapy solution causes blood vessels in the peritoneum to expand, allowing the medication to penetrate more deeply for better absorption. And because the chemo drugs are concentrated in the peritoneal cavity, a higher dose can be administered without causing adverse effects.
There is also the benefit of HIPEC being one treatment given in the operating room immediately after surgery, compared to standard chemo which is delivered intravenously in multiple sessions over several weeks or months.
And, of course, for some patients, especially those who have an aggressive or difficult-to-treat type of cancer, HIPEC may lead to a better outcome and enhanced quality of life.
Who is a candidate for CRS/HIPEC?
Dineen: Since the surgery is invasive, it’s important that candidates for the surgery have a good medical history. HIPEC is most often used to treat patients with appendix cancer, colorectal cancer, stomach cancer or peritoneal mesothelioma. HIPEC can also be effective when used as supportive therapy for patients who have a malignant ascites (an accumulation of fluid in the stomach cavity), which is a common side effect of peritoneal tumors.
What innovations are on the horizon for peritoneal disease?
Dineen: The dedicated research team at Moffitt is continually investigating the effectiveness of new treatments. We have a robust clinical trials program through which patients have opportunities to benefit from promising new surgeries, drug combinations and chemotherapy delivery methods before those options are available in other settings.
Tumor boards are also helping to ensure that every patient is obtaining the best possible therapies for their individual cancer. At Moffitt, our collaborative tumor board meets each week to review progress and make adjustments as necessary.
To learn more about HIPEC or other cutting-edge therapies offered at Moffitt, please reach out to a member of our Gastrointestinal Oncology Program. You can submit referrals for patients without a confirmed diagnosis, as our advanced diagnostic program can help patients get the answers they deserve, and we emphasize short referral times and can accommodate urgent referrals when possible.