Hyperthermic perfusion
Hyperthermic perfusion is a medical technique used to deliver anticancer drugs directly to a specific area of the body, particularly targeting tumors while minimizing systemic exposure to the drugs. This method involves heating a chemotherapy solution and directing it to a cancerous organ or tissue, notably in procedures like isolated limb perfusion and continuous hyperthermic peritoneal perfusion. The heating of the drug solution enhances its effectiveness against various cancers, including melanoma, soft-tissue sarcomas, and peritoneal carcinomatosis.
To perform hyperthermic perfusion, the targeted limb or area is isolated from the rest of the body’s circulation, often requiring preliminary surgeries to remove visible tumors. A perfusion circuit is established using cannulas and specialized pumps to circulate the heated solution. The procedure typically lasts about two hours, followed by monitoring for any complications such as edema or increased bleeding risk due to anticoagulation measures.
Research indicates that hyperthermic perfusion can lead to improved disease-free survival rates for certain cancer types. Ongoing advancements in this technique are expanding its applications, showing promise in treating other malignancies, thus contributing to the evolving landscape of cancer treatment.
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Hyperthermic perfusion
ALSO KNOWN AS: Regional perfusion, isolated limb perfusion, hyperthermic isolated limb perfusion, continuous hyperthermic peritoneal perfusion, intraperitoneal hyperthermic chemotherapy
DEFINITION: Hyperthermic perfusion is a delivery system of anticancer drugs in which a warmed solution containing the drugs is directed to a cancerous organ or tissue by passing the solution through the blood vessels of the area or by bathing the tissue or organ in the solution.
Cancers treated:Melanoma, soft-tissue sarcomas, colon cancer, peritoneal carcinomatosis, liver cancer, lung cancer
Why performed: Hyperthermic perfusion is a technique that allows for maximum exposure of the tumor to anticancer drugs while limiting the toxic effects to the entire body. Heating the chemotherapy solution improves the effectiveness of the anticancer drugs.
Patient preparation: To prepare an area for hyperthermic perfusion, it is necessary to temporarily isolate the circulation of the area from systemic circulation. Additionally, in certain types of tumors (such as peritoneal carcinomatosis), cytoreductive surgery is first performed to remove as much visible tumor as possible prior to isolating the area and proceeding with hyperthermic perfusion.
Steps of the procedure: The arms and legs are frequently the regions exposed to hyperthermic perfusion for the treatment of melanoma or for the treatment of sarcoma of soft tissues. Isolating the circulation of an arm or leg is achieved by putting small tubes (cannulas) in the arteries that carry blood to that limb and in the veins that carry blood out from the limb; this process is called cannulating. In addition, a rubber tourniquet is put at the top of the arm or leg to aid in isolating the area. Thermometers are placed at several locations on the limb to monitor the temperature during the procedure.
A perfusion circuit is established by attaching tubing between the artery and vein cannulas and a special type of pump. The pump apparatus includes an oxygenator (to increase the concentration of oxygen in the blood) and a mechanism to heat and cool the perfusion solution.
Heparin (a blood-thinning substance), a special dye, and electrolytes are mixed with the patient’s blood and circulated through the isolated area. Heparin is used to prevent blood clots from forming, and the dye is used to monitor the perfusion solution and ensure that it does not escape the intended treatment area. The temperature of the perfusion solution is increased (hyperthermia) as it circulates through the isolated area; the anticancer drugs are added when the solution reaches a prescribed temperature. The temperature of the arm or leg, the rate of flow, and the perfusion pressure are all carefully monitored during the procedure. The circulation of the hyperthermic solution lasts for about one hour, and then the anticancer drug is drained from the treated area, and the area is washed out. The whole procedure lasts a maximum of two hours.
Continuous hyperthermic peritoneal perfusion or intraperitoneal hyperthermic chemotherapy uses techniques similar to those used for isolated limb perfusion to deliver a chemotherapy solution to the peritoneal cavity (the space inside the abdomen that has a membrane covering all the organs in the abdomen). Cannulas in the arteries and veins are used with tubing and a pump, and the cavity is sewn shut to create a closed circuit. The entire peritoneal cavity is bathed (perfused) with the warmed chemotherapy solution. Delivering the anticancer drugs directly to the peritoneal cavity allows a much higher dosage of the drugs to be used. As with hyperthermic perfusion of an isolated limb, the procedure for continuous hyperthermic peritoneal perfusion lasts about two hours and ends with draining the drug solution and washing out the peritoneal cavity. Other organs, such as the liver and the lungs, can also be isolated with similar methods.
A variety of anticancer drugs are used in hyperthermic perfusion, including mitomycin C, oxaliplatin, melphalan, cisplatin, doxorubicin, and tumor necrosis factors (TNFs).
After the procedure: Patients are hospitalized and given low doses of heparin to prevent blood clots. If the procedure has been used for an arm or a leg, then that limb is kept elevated for a few days; the period of hospitalization is approximately three days. The hospitalization period for a more extensive procedure, such as cytoreduction surgery in the peritoneal cavity followed by hyperthermic peritoneal perfusion, is approximately ten days.
Risks:Edema (an accumulation of fluid in tissue) is an expected risk or discomfort from the procedure, but it is most often easily treatable. Severe swelling of an arm or leg to the extent that it interferes with circulation is called compartment syndrome; severe cases of compartment syndrome require amputation of the limb. Other expected risks include temporary toxicity to the bone marrow, inflammation of the veins, and an increased risk of bleeding because of the use of heparin.
Results: Research studies have shown an increased disease-free survival of patients for whom hyperthermic perfusion is used. These studies showed results in treating ovarian cancer, late-stage-melanoma, and gastric cancers. In the twenty-first century, advances have been made in hyperthermic perfusion techniques related to the treatment of other cancers as well. In treating pleural malignancies, hyperthermic intrathoracic chemotherapy perfusion involving cytoreductive surgery combined with hyperthermic perfusion directly into the thoracic cavity has shown promise. These two methods, combined with gastrectomy, have also improved the survival rates of patients with gastric cancers. Results of any therapy, however, are dependent upon many factors, chief among them the stage of the cancer at the time of the therapy.
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