New technique may help check spread of cancer

Pressurised Intra peritoneal Aerosol Chemotherapy (PIPAC) is a breakthrough in cancer treatment, where chemotherapy is delivered to confined spaces in the body like abdominal and chest cavities under pressure in spray form to destroy cancer cells through a simple laparoscope. The therapy is best suited for the treatment of ovarian, colon, stomach and appendix cancers that are in advanced stages involving peritoneal cavity, where other conventional therapies fail to treat. It is highly effective in treating cancers that originate from the lining of the abdominal cavity and chest cavity, known as mesotheliomas.

Such cancers are currently being subjected to intense chemotherapy as the first line of treatment, and it is yielding unsatisfactory results. Moreover, multiple chemotherapy sessions also render such patients weak and lead to the development of fluid formation known as 'Ascitis.' PIPAC in such cases is highly beneficial to the patients, as the therapy palliates their symptoms by melting the disease and extending the quality of life.

As no surgery is involved, other than a biopsy for possible NGS studies, is permitted during PIPAC procedure, it is a totally atraumatic undertaking, and it is the beauty of the operation

PIPAC gaining popularity

The other treatment modules, including CRS, HIPEC and third line chemotherapies, are being currently used for the treatment of cancers, but they are giving substandard outcomes.

Surgical treatments

CRS and HIPEC are an extensive supra major surgeries conducted for over 10 hours at a stretch, involves resection of various organs, requiring blood replacements over 8 to 10 units and a longer hospital stay of over 3 weeks. Even though after performing such risky procedure, the complication rates are still high due to its curative intent and costs incurring approximately Rs 9 Lakh.

Similarly, 3rd line chemotherapies are also not very effective and patients are loaded with side effects. Classical Intra peritonel chemotherapy is not as effective as PIPAC because the liquid distribution inside the cavities is not homogeneous and penetration into disease surfaces is low compared to PIPAC.

Radiation therapies

Even though being minimally invasive, the latest Cyberknife and Gamma knife radio surgeries are of no use in extensively advanced disease situations of the abdomen or chest wall, while they are beneficial in cases of minimal disease progression in other body parts. Microwave ablation is used to treat small tumours in liver or occasionally other organs, but it is useless in advanced cancers.

PIPAC currently fulfills an unmet need in cancers disseminated to peritoneum and pleura where nothing better exists. But, the studies are showing that it can also act as Neoadjuvant therapy to downstage extensive abdominal cancers and make them suitable for curative procedures like CRS and HIPEC, subsequently. This is an exciting observation with potential for getting lots of patients into treatment domain that may otherwise have no chance.

In comparison to the above treatment modules, PIPAC is emerging as one of the best game changers for the oncologists, due to the following advantages –

1. No complications: PIPAC has virtually no complications, and the treatment aims for palliation than curative purpose.

2. Cost Effective: In comparison to other treatments, PIPAC costs under Rs 3 Lakh.

3. Minimal hospital stay: Minimising the hospital stay to only 1 day against 2 to 3 weeks as in case of 3rd line chemotherapies.

4. Quicker recovery: With minimal incisions and decreased tumor load to operable mode, the patient makes a better and quicker recovery.

Potential of PIPAC in India

The technique is originated recently in Tubingen Germany by Prof Marc Rubens, and it is still evolving. Multiple clinical trials are underway to collate solid evidence in its favour. Only a few centers in the world like France, Germany and US have experience and our center in India is one of them. As more and more centers acquire this expertise, it would become more popular in the future.

Depending upon the type of primary cancer, the outcomes of PIPAC therapy may vary. For instance, in cases of advanced (Stage IV) ovarian cancer, the objective response rates are very high (over 70%) with better survival (14 months) in comparison to other currently used methods. Appendix and colon also have similar noteworthy results, but outcomes in cases of gastric cancer are not so good due to its adverse biology. PIPAC provides a significant improvement in the quality of life.

Patient satisfaction

Many patients suffering from advanced stages of ovarian, colonic and appendicle cancer have achieved astounding results. Since there are absolutely no side effects and patients can walk out of the hospital, they are usually satisfied and happy. They come back for repeat procedures after 6 weeks or so, which is recommended as well.

Infrastructure for PIPAC

One requires an operating room with laminar airflow or fitted with a Hepa filter, so that minute aerosol particles of chemotherapy are sucked out. Laproscopic cart and scope, a double chamber high pressure injector, a Buffalo filter to suck out vapours, and the last but not least, a uniquely developed aerosoliser called 'Capnopen' are needed. Of course, the performing surgical oncologist should be trained for the procedure. It is performed with patient under general anaesthesia.

(Writer is president of Brest Cancer Patient Benefit Foundation)

By Dr Sameer Kaul