Intraperitoneal chemotherapy for treatment of ovarian cancer
- Maurie Markman, MD
Maurie Markman, MD
- Clinical Professor of Medicine
- Drexel University College of Medicine
- President, Medicine & Science
- Cancer Treatment Centers of America
- Alexander B Olawaiye, MD
Alexander B Olawaiye, MD
- Associate Professor of Obstetrics, Gynecology and Reproductive Sciences
- University of Pittsburgh
- Section Editors
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Professor of Gynecologic Oncology
- University of Washington
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Clinical Co-Director, Gynecologic Oncology
- Founder and Director, The Oncology Sexual Health Clinic
- Massachusetts General Hospital Cancer Center
- Associate Professor of Medicine
- Harvard Medical School
- Deputy Editors
- Sadhna R Vora, MD
Sadhna R Vora, MD
- Deputy Editor — Oncology
- Instructor in Medicine
- Harvard Medical School
- Sandy J Falk, MD, FACOG
Sandy J Falk, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Clinical Instructor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
The most common route of ovarian cancer spread is within the peritoneal cavity. The rationale for administering chemotherapy directly into the peritoneal cavity is supported by preclinical, pharmacokinetic, and pharmacodynamics data. Compared with intravenous (IV) treatment, intraperitoneal (IP) administration permits a several-fold increase in drug concentration to be achieved within the abdominal cavity. In addition, clinical trials have demonstrated a survival advantage to the incorporation of IP treatment in the upfront management of ovarian cancer.
The rationale and technical issues related to IP chemotherapy for ovarian cancer will be reviewed here. A more extensive discussion on the data to support the use of IP treatment in ovarian cancer is covered separately. (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management" and "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer".)
In the vast majority of patients, epithelial ovarian cancer (EOC, which includes fallopian tube and peritoneal cancers) is confined to the peritoneal cavity at initial diagnosis and in recurrence . Because of this natural history, ovarian cancer is an ideal target for intraperitoneal (IP) therapy. Pharmacokinetic studies have demonstrated that IP administration of chemotherapy results in high peritoneal to plasma ratios for peak concentration for cisplatin, paclitaxel, carboplatin, and docetaxel . The higher peritoneal concentration is hypothesized to improve efficacy by increasing concentration of the cytotoxic agent in the tumor microenvironment. Analysis of intratumoral drug concentrations demonstrates that lesions 2 to 3 mm or smaller will have significantly higher drug exposure from intraperitoneal administration as compared with intravenous administration . In addition, avascular tumors are exposed to higher drug concentrations with intraperitoneal compared with intravenous delivery, while systemic exposure and associated toxicity is minimized [4,5]. (See "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer", section on 'Intraperitoneal chemotherapy'.)
Indications for IP chemotherapy — Based on available clinical data, intraperitoneal (IP) chemotherapy may be most useful in women with optimally debulked (to ≤1.0 cm) stage III epithelial ovarian cancer (EOC). Some patients with earlier-stage disease may also be candidates (see "Adjuvant therapy of early stage (stage I and II) epithelial ovarian, fallopian tubal, or peritoneal cancer", section on 'Selection of patients'). Those patients who have been cytoreduced to no gross residual disease seem to have the greatest benefit from IP chemotherapy and improved overall survival.
Furthermore, some experts also utilize IP chemotherapy for women treated with neoadjuvant chemotherapy who undergo an optimal interval cytoreduction. However, there are no prospective data to evaluate this strategy, and we await data from the OV.21 trial to inform this decision . The management and choice of chemotherapy for EOC is discussed separately. (See "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer".)
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- PATIENT SELECTION
- Indications for IP chemotherapy
- TECHNICAL ISSUES
- Timing of placement
- IP catheter and port
- CHEMOTHERAPY ADMINISTRATION
- Intravenous hydration
- - Nephrotoxicity
- - Neurotoxicity
- - Abdominal pain
- - Hypersensitivity reaction
- - Inability to access port or infuse the drug
- - Leakage of infusate
- - Gastrointestinal complications
- Diagnostic evaluation
- Bowel obstruction
- Gastrointestinal necrosis or perforation
- CATHETER REMOVAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS