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  • The PIPAC technique allows chemotherapy to penetrate deeper into tissue with fewer adverse effects in comparison with conventional chemotherapy and chemotherapy administered by the HIPEC technique
  • Although PIPAC is currently only indicated in cancer patients with peritoneal metastases who are not candidates for curative surgery, the option of using PIPAC to reduce disease volume is being studied
  • MD Anderson Cancer Center Madrid is the only hospital offering this innovative technique in Madrid and one of three doing so in the countr

The administration of pressurized intraperitoneal aerosol chemotherapy (PIPAC) offers new treatment options for patients with peritoneal carcinomatosis, that is, with metastases in the peritoneum, who are not candidates for curative surgical treatment. "Intravenous systemic chemotherapy is the standard treatment in patients with advanced cancer which cannot be completely removed due to the great volume of the disease," says Dr. Gloria Ortega, of the Surgical Oncology Service of MD Anderson Madrid. "The problem is that patients in treatment with systemic chemotherapy begin to have numerous complications derived from the treatment," specialist goes on, who points out that PIPAC is treatment that, while used in combination with systemic chemotherapy, "allows the disease to be controlled with fewer adverse effects".

Comparing intravenous systemic chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC), a technique also widely used today for the treatment of peritoneal metastases, Dr. Ortega emphasizes that "PIPAC has greater capacity of tissue penetration and with fewer adverse effects, since a lower dose of chemotherapy is used". In addition, while PIPAC is always administered laparoscopically, HIPEC is usually administered laparotomically, that is, with open surgery.

"The main advantage of PIPAC is that the gap between sessions of systemic chemotherapy can be extended," states Dr. Ortega, who also says a PIPAC cycle can be followed by two cycles of systemic chemotherapy, another of PIPAC, two of systemic chemotherapy and so on, so the patient would be able to have a kind of  rest form treatment whilst reducing the side effects of treatment. Furthermore, by administering treatment in cycles, peritoneal lesions can be biopsied after each of these cycles, which allows us to see in real time if the treatment is giving results". In fact, the doctor states that given the good results of the technique, "the next step could be to offer surgery to patients who respond to the treatment, although this would be in the longer term in neoadjuvance".

For the moment, patients in whom this technique is indicated are mainly those with gastric cancer who have peritoneal metastases and who are not candidates for surgery or HIPEC and those with platinum-resistant ovarian cancer who are not candidates for surgery either. Although it is used to treat colon cancer and other tumors with metastases in the peritoneum, at present gastric cancer, followed by ovarian cancer, are the pathologies in which this technique is most used.

A simple procedure with a duration of less than one hour

Once the instruments are in place to proceed with the laparoscopic technique, chemotherapy is administered and left to act for thirty minutes, although there is already ample research into a new PIPAC system, ePIPAC, which would obtain the same results in just two or three minutes. “Electrostatic PIPAC, or ePIPAC, helps the aerosolized drops of chemotherapy to fall and, in this way, the time needed for the chemotherapy to act is reduced", explains Dr. Ortega.

In addition, the possibility of administering this aerosolized chemotherapy at high temperatures is also being studied, as in the case of HIPEC, instead of at a normal temperature of 37º Celsius, as is currently done. But both hyperthermic PIPAC, hPIPAC, and HINAT, which uses even smaller particles of chemotherapy, are possible advances in PIPAC that are still in the early stages. "This is all still in the research stage, but it is true that PIPAC is proving to be a fascinating field of research and possibilities," says the specialist.