It will soon be four decades since surgeon Paul H. Sugarbaker sparked global controversy by raising the possibility of treating advanced peritoneal disease through cytoreductive surgery plus the administration of hyperthermic intraoperative chemotherapy (HIPEC). By applying hot chemotherapy directly to the tumor cells, the aim is to destroy the residual microscopic disease, because, in the words of the American doctor, “what the surgeon does not see kills the patient.”
Since then, the technique has been applied to peritoneal carcinomatosis of gastric, colorectal, appendiceal and ovarian origin, as well as primary tumors of the peritoneum. In certain indications, such as ovarian cancer, the use of HIPEC has not become widespread in Spanish centers pending new evidence to support it.
This is how oncological surgeon Juanjo Torrent, founder of QTI (Quénet Torrent Institute), in Barcelona, sees it, who points out that “the HIPEC controversy is due to the heterogeneity of previous publications, in terms of drugs, doses, timing of indication, etc. The surgeon is one of the authors of the clinical trial on HIPEC in ovarian cancer recurrence (Chipor, Chemotherapy Hyperthermic Intraoperative in Ovarian Cancer Relapse), which demonstrates the usefulness of the technique in this advanced disease. In ovarian cancer, “in Spain HIPEC is not very widespread for different reasons. Probably, gynecological oncologists were waiting for the results of these studies, since now various teams are beginning to perform them.”
One of those studies is precisely Chipor, which was presented at the meeting of the American Society of Medical Oncology (ASCO) last June; at the European congress of gynecological oncology (ESGO, held in Istanbul in September) and, finally, a little over a week ago at the Psogi congress (organization on diseases of the peritoneum, such as carcinomatosis), in Venice. All three, leading conferences in oncological pathologies.
QTI-Quénet Torrent Institute surgeons Juanjo Torrent and François Quénet are part of the authors of this international study, in which numerous centers have participated. Here, a total of 415 patients with ovarian cancer recurrence were analyzed, who were compared in two arms: in one, 208 patients were treated with chemotherapy and surgery, and in the other, 207 patients were treated with chemotherapy and surgery. with HIPEC.
“The trial shows that patients with ovarian cancer recurrence, to whom we administer chemotherapy and then operate and at the same time perform HIPEC, have longer survival (10 months longer than the average), than those who do not perform HIPEC” , comments Juanjo Torrent. A moderate increase in illness-free time was also observed.
Toxicity is no excuse.
“The benefited patients are all those who have a recurrence of platinum-sensitive ovarian cancer, that is, in whom the cancer has reappeared with a disease-free interval of a minimum of 6 months since the last cycle of chemotherapy. Other evidence in this trial and in other recently published trials is that HIPEC does not increase toxicity, so we already know that this argument does not justify its non-performance,” the surgeon emphasizes.
The clinical study continues in line with the latest phase III trials on HIPEC in the treatment of ovarian cancer, which reflect an improvement in the survival of patients who are administered intraoperative chemotherapy.
“More phase III studies are currently underway that analyze the application of HIPEC at other times of treatment (without prior chemotherapy), so in the coming months or years we will know if we can extend the indications for HIPEC in ovarian cancer” .
The decision whether or not to add HIPEC to surgery in ovarian cancer recurrence is clear: intraoperative chemotherapy increases survival without added toxicity.