의학 이야기2017. 7. 17. 16:49

[Dr. Essay] “The cancer has spread to the peritoneum?”

사본 -이채영A patient who has undergone surgery and exhausting chemotherapy for gastric cancer is sitting in front of a doctor waiting to hear the results of his regular check-up.
Doctor: (Upon carefully looking at a CT image) “It’s bad news, I’m afraid. The cancer has spread to your peritoneum.”
Patient: “But you can treat that cancer just like you’ve treated me up until now, right Doctor?
Doctor: (Looking uncertain) “Of course we will do everything that we can for you, but I’m afraid it’s most likely that we won’t be able to completely cure the peritoneal cancer. The chemotherapy you will now undergo will be a most difficult experience, but you must fight through it.”
 The patient looked into the eyes of the unsure doctor and felt a dark cloud come over him. The doctor told him that the chemotherapy drugs he was on were no longer working at full efficacy and would need to be replaced by other drugs.
 Patient: “What are the odds of peritoneal cancer being cured using chemotherapy?”
Doctor: “This is not an exact number, but my estimation is probably about 15%. Even if the treatment works, its effects will only increase life expectancy by about 2 to 3 months.”
Patient: “If the chances of survival are so poor, then why go through the trouble of having chemotherapy?”
Doctor: It will increase the length of your life, even if just by a short while. If you don’t have chemotherapy, you won’t live to see even the next few months.
Patient: “Are there no other treatment options available besides chemotherapy?”
Doctor: “……”
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종양외과 이채영 과장 시술 사진(라이펙 시술 장면)It has already been seven years since LHIPEC surgery was first introduced in August 2008. Patients who are diagnosed with peritoneal metastasis are usually faced with a difficult question, which usually goes something like, “Should I go through painful chemotherapy to live an extra few months, or just give up and die?”After hard contemplation, many of them head out in search of medicines and supplements, etc. which are “good for cancer patients”. This makes me sad to see as a cancer surgeon.

“The cancer has spread to your peritoneum.” Patients who hear these words often don’t understand the seriousness of what they imply. To put it simply, it is akin to saying, “We’ve reached the limits of treatment and now it’s time to give up.” The most commonly prescribed treatment for peritoneal cancer and peritoneal metastatic cancer is chemotherapy. The problem, however, lies in the fact that the effectiveness of chemotherapy could be described as poor at best. If the cancer has spread to the peritoneum, then it is likely that all the good chemotherapy drugs have already been used, so the second and third drugs to be used are less effective and don’t reach the affected areas in the peritoneum.

Let’s take a look at the issue through some questions and answers about peritoneal metastasis.


Why does peritoneal metastasis occur? 
Cancer cells can spread to the peritoneum via lymphatic vessels or blood vessels, but it is thought that it is usually caused by cancel cells spreading to the abdominal cavity. These cells make the blood vessels of the peritoneum weak, causing nutrition to leak through, nourishing the cancer cells.


Why is it difficult to treat peritoneal metastasis?
When observing peritoneal tumors through a camera, they are mostly white in color. This means that there are no blood vessels in the nodes. No matter how good the anti-cancer drugs are that enter the blood vessels, because they don’t reach the lesions in the peritoneum, the treatment is ineffective. As the disease worsens, the tumors get bigger and begin to form blood vessels, but in cases where they are just hanging on to the abdominal wall, they have no blood vessels.


What are the symptoms and lapse time of peritoneal metastasis?
About 70% of patients who have cancer that has spread to the peritoneum complain about an uncomfortable feeling of a buildup of fluid in the abdomen (Ascites). They can’t eat properly and suffer from abdominal pain. If it gets more serious, the insides are pressed together, causing intestinal adhesion, and eventually become blocked making the patient unable to eat anything at all.


I’ve heard that chemotherapy is generally used to treat peritoneal cancer. Are there no other available treatments?
Chemotherapy, which affects the entire body, is not very effective at treating cancer that has spread to the peritoneum. Treatments developed in order to overcome this problem are peritoneal resection and laparoscopic hyperthermic intraperitoneal chemoperfusion. It was first introduced by Professor Sugarbaker of the Washington Cancer Center, and is now also being actively used in Europe and Japan.


What is LHIPEC?
LHIPEC is short for Laparoscopic Hyperthermic Intraperitoneal Chemoperfusion, which simply means, treatment for cancer in the peritoneum (abdominal cavity) using a laparoscope (a thin, lighted tube put through a cut (incision) in the belly) and high heat (hyperthermic). Intraperitoneal hyperthermic chemoperfusion requires an incision (cut) to be made in the belly in order to insert a laparascope, and Anyang SAM Hospital first began using this method in 2008. The laparoscope is used to observe tumors/lesions, and if necessary, synechotomy is used, and chemotherapeutic drugs are inserted into the peritoneum with a temperature of 41-43 degrees being maintained for about 1 hour. The total treatment time is about 2-3 hours.


Why is heat applied in combination with chemotherapy?
If the heat is raised to 41-43 degrees, the efficacy of the chemotherapy drugs increases, and the depth of penetration into the tissue also increases, bringing about a synergy effect.


What are the advantages of LHIPEC surgery?
Because LHIPEC uses a laparoscope, experienced pain is minimal and recovery is fast. The degree of progression of peritoneal metastasis can be accurately ascertained visually. In addition, it has a remarkable effect on managing abdominal fluid levels. Since it directly kills metastatic cancer cells, it reduces the chance of recurrence significantly. Intestinal bypass and enterostomy can also be performed at the same time.


What are the typical results of LHIPEC?
According to analytical results, it has an excellent effect on managing abdominal fluid levels, and improves life expectancy compared with conventional treatments. We hope that many peritoneal metastasis patients are benefited by this treatment method.

 

Written by Lee, Chai-young,
Director of Surgical Oncology Center at G SAM Hospital
(Chief of Integrated Cancer Center)


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