1. Perron, Michelle

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Two Northwestern Medicine surgical teams recently collaborated to perform a unique surgery on a man with metastatic appendiceal cancer that had spread to his chest and lung. During the procedure, known as hyperthermic intrathoracic chemotherapy (HITHOC), surgeons removed the metastatic tumors and then circulated heated chemotherapy throughout the thoracic cavity to kill residual cancer cells. It was the first HITHOC procedure at Northwestern Medicine and is believed to be the first performed in Illinois.

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John D. Abad, MD, Director of Surgical Oncology and GI Oncology at Northwestern Medicine Central DuPage Hospital, and Ankit Bharat, MD, Chief of Thoracic Surgery at Northwestern Memorial Hospital, performed the surgery on July 9. During the 7-hour procedure, Abad and Bharat led a team of professionals from both Northwestern facilities. "We used the talents of the health system to help a single patient," Abad said. "It was a great example of how we work together."


The Right Opportunity

Although the HITHOC procedure was a first for Northwestern, the use of perfusion techniques to combat metastases was not new to the surgeons. Abad and Bharat had each been exposed to HITHOC in previous treatment and training settings, and both were alert to the possibility of introducing it at Northwestern. Abad had significant experience with hyperthermic intraperitoneal chemotherapy (HIPEC) and had introduced the procedure at Northwestern around 2015. HIPEC is used in abdominal cancers and is much more common than HITHOC.


"I knew that Dr. Bharat was looking to build a thoracic chemotherapy perfusion program, but hadn't had a patient who was a good candidate," Abad said. "We had the expertise in the abdomen (HIPEC) to perform the procedure, and felt comfortable executing a similar operation in the chest."


A Chicago area patient in his 60s turned out to be an ideal fit. He had been diagnosed in early 2019 with appendiceal cancer, which often metastasizes aggressively throughout the abdomen and pelvis. At that time, Abad performed HIPEC as a cytoreduction measure.


"He had a tremendous amount of disease and that procedure took about 15 hours," Abad said. "We took out visible disease in the abdomen; several organs including the spleen, pancreas, and liver; portions of the intestinal tract; and a significant portion of the right diaphragm. We then gave him chemotherapy throughout the abdomen for 90 minutes. He tolerated it well and recovered well, but he did develop recurrence."


The patient's recurrence pattern was unusual. "There was significant disease along the diaphragm and migration of tumor into the right chest," Abad said of the patient's presentation in 2020. "The bulk of disease was in the right chest when it recurred."


The patient was treated with chemotherapy, but the chest tumor continued to grow. "That's when we looked into HITHOC following removal of all visible disease by stripping thoracic surfaces and part of the lung," Abad said. "We would deliver chemotherapy directly to portions of the chest and circulate it during surgery."


Teamwork in Action

The surgical oncology team from Northwestern Central DuPage and the thoracic oncology team from Northwestern Memorial collaborated to execute the innovative surgery. Perfusion and anesthesia team members were particularly key to the procedure.


"Dr. Bharat and I had many conversations about the approach and what it would require to have this patient's disease completely removed," Abad said. "As much as you think ahead, however, a lot of planning happens in real time during surgery. You can't see the exact extent of disease until then, and you have to formulate a plan on the spot."


Once the surgery was under way, the two surgeons saw that the patient's disease recurrence had been underestimated by preoperative imaging studies. This is not uncommon, Abad noted.


"We had seen some slow progression on imaging. He was doing quite well and pretty symptom-free at the time of surgery. We thought that it was an appropriate time to operate," he said. However, the patient had more extensive disease of the pericardium, diaphragm, and pleura than was expected.


Despite the greater extent and severity of disease, the surgery achieved its goals of reducing disease, and the patient was discharged after 4 days in the hospital. When interviewed about the procedure in late August, Abad said the patient was doing well and would likely resume chemotherapy treatments because he is still at risk for recurrence.


The exact effects of perfusion chemotherapy are dictated by the biology of the tumor, Abad explained. "For low-grade tumors of the appendix and low-grade tumors in general, the rates of response and cure are much higher. The more aggressive the tumor biology, the more likely it will come back," he said. "But often it buys time and provides a survival benefit. We can't necessarily provide cure, but we try to move the timeline back to give more time for family and patient."


Importance of Patient Selection

Deciding to perform a complex procedure like HITHOC requires careful patient selection and thorough patient understanding about the surgery, its risks and its benefits. Because Abad had performed the HIPEC procedure on this patient early in his disease course, the two had a firm foundation to build upon.


"This patient had questions, certainly, but he has a lot of confidence in our teams and the technique," Abad said. "He had done really well with the first perfusion, so he understood it as well as the risks. He was open to it and a believer in using perfusion for his type of cancer.


"Besides the element of teamwork, patient selection is the underlying story in this case," Abad continued. "There are many things we can do, but it's having the right patient and the right time and the right circumstances that really works at providing the best outcomes. Patient selection is extremely important for this surgery. For those who can benefit, it's a very aggressive intervention that can provide tremendous impact."


Michelle Perron is a contributing writer.


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