Pressurized Intra peritoneal Aerosol Chemotherapy (PIPAC) is a breakthrough in Cancer treatment, where chemotherapy is delivered into confined spaces in the body like abdominal cavity and chest cavity under pressure in spray form to destroy cancers which have spread there thru a simple laparoscope. The therapy is best suited for treatment of cancers of Ovaries, Colon, Stomach, Appendix which are at the advanced stages involving the 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 which are currently being subjected to intense chemotherapy as the first line of treatment have provided with unsatisfactory results. Moreover, multiple chemotherapy sessions also render such patients weak and leads to development of fluid formation known as ascitis. PIPAC in such cases are highly beneficial to the patients as the therapy palliates their symptoms by melting the disease and extending the quality of life. As no surgery other than taking a biopsy for possible NGS studies is permitted during PIPAC procedure, it is a totally atraumatic undertaking, being the beauty of this operation
PIPAC gaining popularity for treating advanced cancers
While other treatment modules including CRS, HIPEC and third line chemotherapies are being currently being used for treatment of cancers, but with substandard outcomes.
Surgical treatments – CRS and HIPEC are an extensive supramajor surgeries conducted for over 10 hours at a stretch, involves resection of various organs, requiring blood replacements over 8-10 units and a longer hospital stay of more than 3 weeks. Even though after performing such risky procedure, the complication rates are still high due to its curative intent and costs approximately INR 9 Lakhs. Similarly, 3rd line chemotherapies are also not very effective and patients are loaded with side effects. Classical Intraperitonel 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 radiosurgeries are of no use in extensively advanced disease situations of the abdomen or chest wall, while 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 is useless in advanced cancers. PIPAC currently fulfills an unmet need in Cancers disseminated to peritoneum and pleura where nothing better exists. But studies are showing 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 who 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/ Safer procedure – 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 INR 3 Lakhs.
3. Minimal Hospital stay – Minimizing the hospital stay to only 1 day against 2-3 weeks in case of 3rd line chemotherapies.
4. Quicker recovery – With minimal incisions and decreased tumor load, making tumors operable, the patient makes a better and quicker recovery.
Potentials of PIPAC in India
This technique originated recently in Tubingen Germany by Prof Marc Rubens and is still evolving. Multiple clinical trials are underway to collate solid evidence in its favour. Only a few centres in the world like France, Germany, US have experience and our centre in India is one of them. As more and more centres acquire this expertise it will become popular in 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.
Clinical Outcomes & Patient satisfaction
Many patients suffering from advanced stages of ovarian, colonic and appendicular 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 required 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 last but not least a uniquely developed aerosoliser called Capnopen are needed. Of course the performing Surgical Oncologist should be trained for this procedure which is conducted with patient under General anaesthesia.
(The author is President, BCPBF-The Cancer Foundation. Views are his own, firstname.lastname@example.org)