Thriving Under Pressure: Aerosol-Based Treatment for Abdominal Lining Cancer comes to New Jersey

Hackensack Meridian JFK University Medical Center is among handful of sites in the U.S. to offer PIPAC

When diagnosed with peritoneal carcinomatosis (cancer of the abdominal lining), treatment – including surgical removal of affected organs and heated chemotherapy – can be challenging. But an innovative, aerosol-based therapy developed in Europe to treat the disease has been embraced here in America by a dozen or so sites, most recently at Hackensack Meridian JFK University Medical Center. Hackensack Meridian Central Region Surgical Oncology Chief Benjamin Golas, MD, FACS, and Eric Pletcher, MD, surgical oncologist at JFK, who along with a specially trained multidisciplinary team, recently performed this procedure. They share more about the laparoscopic surgical treatment known as PIPAC - pressurized intraperitoneal aerosolized chemotherapy.

What is peritoneal carcinomatosis, and what is the challenge in treating it?

Peritoneal carcinomatosis is a rare form of cancer in the abdominal cavity that can occur from the spread (metastasis) of cancer from other organs including the colon, rectum, ovaries, stomach or pancreas - or originate directly from the abdominal cavity lining (i.e. mesothelioma). Systemic chemotherapy delivered throughout the entire body is one approach, but classically, it’s very difficult to target the peritoneal lining through this method.

Tell us about PIPAC and how it compares to the current ‘standard of care.’

The PIPAC approach is a less invasive – and more direct – way of delivering chemotherapy to the abdominal cavity. It’s a laparoscopic approach where a few small incisions in the abdomen are made. A small camera is inserted, followed by a pen-like device that injects an aerosolized version of chemotherapy into the peritoneal lining. The advantage of offering treatment administered through a pressurized delivery mechanism results in a more targeted and effective distribution of chemotherapy without significant side effects.

Typical treatment for peritoneal cancer can range from systemic chemotherapy to cytoreductive surgery and/or a procedure called HIPEC. Cytoreductive surgery (CRS) is a debulking surgery in which tumors and affected tissue are removed. This sometimes includes the removal of organs and can result in procedures that are 10 to 12 hours long. CRS can also be coupled with HIPEC (hyperthermic intraperitoneal chemotherapy), a procedure that bathes the abdominal cavity in heated chemotherapy. Recovery from CRS and HIPEC can mean a hospital stay of 10 days to two weeks. With PIPAC, the entire procedure lasts about 90 minutes and patients typically go home the same day.

PIPAC can be given as adjuvant therapy concurrently with chemotherapy to further ensure that as many cancer cells as possible are destroyed. It can also be used as a type of ‘bridge therapy’ given prior to CRS/HIPEC for maximum impact. For this route, we’ll use PIPAC to stunt the growth of any tumors so that there’s a better chance of removing them during the debulking surgery. We can then treat for side effects. Given the ease in which PIPAC can be performed, it can be given as a series of treatments - each six to eight weeks apart. It is also used in a palliative sense to help alleviate symptoms for those patients with a significant number of tumors.

Who is an ideal candidate for PIPAC?

Any patient with peritoneal carcinomatosis is a candidate for this procedure. It’s particularly beneficial for those who aren’t suitable for CRS/HIPEC due to extensive disease or limited functional status. While CRS/HIPEC is effective, not all patients with peritoneal cancer are eligible, especially if complete or near-complete tumor removal is unlikely. Furthermore, HIPEC isn't always tolerated. Since PIPAC is a minimally invasive, laparoscopic alternative with minimal side effects, it can be integrated easily into most treatment plans, often in combination with other therapies. And now with PIPAC in our treatment arsenal, we have a greater potential for improved patient outcomes.

Why isn’t PIPAC widely available?

At Hackensack Meridian Health and JFK University Medical Center - both as a network and a hospital - we continually strive to offer new and emerging technologies and treatments that will make a difference in the lives of our patients. Since JFK is an established leader in CRS/HIPEC, adding PIPAC was a natural next step given the unique support system and specialized team we already have in place.

Logistically, the procedure is dependent on a multidisciplinary approach involving more than 30 people across several teams who have undergone extensive training over a course of several months to deliver this treatment in a controlled environment. This includes a specialty pharmacy team that ensures the correct dosing for the aerosol form of treatment and others who oversee the power injector mechanism itself, ensuring the pressure and delivery of the aerosol is appropriate. An attitude of collaboration and teamwork has been key in our ability to bring this novel treatment approach to New Jersey.

What is the significance of being able to offer this treatment approach?

Our first patient has significant peritoneal carcinomatosis from appendix cancer. He had significant fluid in his abdomen (i.e. ascites) and was not a candidate for CRS/HIPEC. He was treated with multiple regimens of systemic chemotherapy with little to no effect. He underwent a successful PIPAC procedure that alleviated his ascites and will hopefully allow him to bridge to an eventual CRS/HIPEC. For patients with peritoneal carcinomatosis that are looking for alternative treatments, PIPAC provides another advanced therapy alternative that is convenient and minimizes debilitating side effects, helping to improve patient outcomes.

To learn more about PIPAC treatment at JFK University Medical Center, call 732-635-9300. To learn more about oncology services across Hackensack Meridian Health and at John Theurer Cancer Center, visit hackensackmeridianhealth.org/cancer.