Unique Chemo Administration ‘Provides Hope’ for Children With Peritoneal Cancer

Hyperthermic intraperitoneal chemotherapy, which was originally available to treat adults, can now be used in children as part of a treatment plan for tumors that are difficult to access during surgery.

Children with desmoplastic small round cell tumors were previously treated with systemic chemotherapy and surgery. Hyperthermic intraperitoneal chemotherapy involves warmed chemotherapy inserted directly into the abdomen cavity rather than the blood stream, which allows for a deeper treatment effect and fewer side effects.

CURE® spoke with Dr. Erika Newman, associate professor of surgery and surgical director of the multidisciplinary solid tumor oncology program (MSTOP) at University of Michigan C.S. Mott Children’s Hospital in Ann Arbor, to learn more about the benefits of hyperthermic intraperitoneal chemotherapy, why it’s now available for use in children and how a team can help ward off side effects before they occur.

Why can hyperthermic intraperitoneal chemotherapy now be used in children?

Like most treatments, particularly medications that have the potential to be toxic, typically those are studied (and) piloted in adults and in adult cancers. There are very few chemotherapies that have been studied and targeted directly to pediatric cancers. In fact, that's a limitation of pediatric cancer care and treatment, is that nearly all of the current chemotherapy that's used was first studied and targeted towards adult cancers, which are very different from pediatric cancers. That's why some of the pediatric cancers like the ones that I treat are so difficult to treat, because the therapies are geared towards adult cancers. When you look at research funding, the (National Institutes of Health) and other funding mechanisms, the percentage of grants and grant funding for pediatric tumors is very low. It's quite frustrating, actually, to work in this field, where most of our cancers are orphaned tumors.

(Hyperthermic intraperitoneal chemotherapy) was pioneered in adults and for adult cancers and tumors. Over the years and over time, this was studied. Dr. Andrea Hayes-Jordan is the one who pioneered this in kids at (The University of Texas) MD Anderson Cancer Center. She published the results of her study, and for a long time, many of us would send our kids there (because) she had the most experience, she was the one doing (hyperthermic intraperitoneal chemotherapy). She published those results that we could extend the life of a certain population of cancers if we did (hyperthermic intraperitoneal chemotherapy) in some (patients). There are a few centers now that are willing to take this on, and ours is one of them. This was made possible and driven by the hard work and dedication of the multidisciplinary team: oncologists, surgeons, perfusionists, pharmacists, nurses, operating room team, trainees and our MSTOP director/APP, Tammy Stoll.

What cancer types does this treat in children?

The one that we know and the one that's been studied is the desmoplastic small round cell tumor. That's a tumor that attaches to the lining of the abdomen inside and the peritoneal cavity. Other cancers, there are certain sarcomas that will attach and grow in the abdominal wall, and so those are the cancers that we typically utilize.

What can children and their caregivers expect if one is to undergo hyperthermic intraperitoneal chemotherapy?

One thing that's really important is that (hyperthermic intraperitoneal chemotherapy) is a component of a full treatment plan. Patients will still get neoadjuvant chemotherapy, or chemotherapy before surgery. They get anywhere from six to eight cycles, and then we go into what we call local control surgery, where we remove all of the remaining tumors on all abdominal surfaces, along with giving the intraperitoneal chemotherapy that's warmed into the abdominal cavity. And so what (hyperthermic intraperitoneal chemotherapy) does is that it allows us to get a really high dose of chemotherapy directly into the abdomen and into tumor cells that may not be visible. The idea is that it would directly start to impact cancer lining the entire peritoneal cavity rather than giving that intravenously.

What are some of the side effects associated with hyperthermic intraperitoneal chemotherapy?

It has actually been pretty well tolerated in children. One of the things that we worry about is renal or kidney toxicity. We do a lot to prevent that. We bring the kids in the night before (the surgery) and make sure that they're really well hydrated. We hydrate them before, during and after the procedure to protect their kidneys. There are a few medications that we give in the operating room during the (hyperthermic intraperitoneal chemotherapy) surgery to protect the kidneys. We do a lot to try and protect kidney and kidney function.

Currently, only a few centers can administer this treatment. Can centers across the country be trained to do this?

I think so. Similar to the adults, there were only a few centers doing this very early on, and then as it became more known that this is a safe procedure, that it's well tolerated and that we can potentially extend survival, then more centers began to build our programs.

You definitely need a program, meaning you need multidisciplinary expertise and input. You need an oncologist who can help with chemotherapy and dosing. You need surgeons who can feel comfortable operating. The operation can be very technically challenging because many of these tumors are in locations that may be difficult surgically. You need radiologists to help interpret some of the difficult scans. You need (a) pathologist (and a) perfusionist, you need an operating room staff that can orchestrate complex cases.

This is not something that can be done in centers that are not used to taking care of really sick children with cancer. You need a knowledgeable multidisciplinary team with expertise in pediatric solid tumors.

What impact do you think hyperthermic intraperitoneal chemotherapy can have on children with this specific cancer?

I think what inspires me the most about (hyperthermic intraperitoneal chemotherapy) is that it provides hope for patients that may not necessarily have many other treatment options. We can do this and provide hope that we will increase survival both short- and long term. To me, that’s so inspirational. And it's so exciting to be able to offer this and be able to provide a chance for kids to be reunited with their families.

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