Intraperitoneal chemotherapy for treatment of ovarian cancer
- Joan L Walker, MD
Joan L Walker, MD
- Section of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- University of Oklahoma Health Sciences Center
- Maurie Markman, MD
Maurie Markman, MD
- Clinical Professor of Medicine
- Drexel University College of Medicine
- Vice President for Patient Care Services
- National Director of Medical Oncology
- Cancer Treatment Centers of America
The most common route of ovarian cancer spread is within the peritoneal cavity. The benefit of administering chemotherapy directly into the peritoneal cavity is supported by preclinical and pharmacokinetic 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 demonstrated that IP administration of chemotherapy results in high peritoneal to plasma ratios for peak concentration, including for cisplatin, paclitaxel, carboplatin, and docetaxel . (See "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer", section on 'Intraperitoneal chemotherapy'.)
Intraperitoneal (IP) therapy is best suited to patients with no or minimal residual disease after surgical cytoreduction because penetration of chemotherapy into tumor tissue is limited to a few millimeters of tumor on the peritoneal surface layers. Therefore, IP chemotherapy is indicated for women with optimally debulked (to ≤1.0 cm) stage III epithelial ovarian cancer (EOC). In addition, some data suggest that patients with stage II disease have a higher risk of relapse than those with stage I EOC. For example, in the randomized Gynecologic Oncology Group 157 trial (GOG 157), patients with stage II disease had an almost twofold increased risk of relapse compared with those with stage I disease (31 versus 18 percent, respectively) . This has led to wider inclusion criteria for IP treatment, and some experts now offer it to women with stage II disease. While controversial, some experts also will 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. The National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) have completed enrollment in the OV.21 randomized trial, which sought to evaluate the role of IP therapy after neoadjuvant chemotherapy, and results are eagerly anticipated .
Of importance, there is wide agreement that IP chemotherapy should not be administered in the setting of stage IV EOC (table 1) and in patients with suboptimally cytoreduced disease (ie, residual tumor greater than 1 cm in diameter).
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- PATIENT SELECTION
- BENEFITS OF TREATMENT
- TECHNICAL ISSUES
- IP catheter and port
- - Placement during initial laparotomy
- - Delayed insertion
- Bowel resection
- Considerations for surgery in patients who are candidates for IP treatment
- PROCEDURE FOR CHEMOTHERAPY ADMINISTRATION
- Related to chemotherapy
- - Nephrotoxicity
- - Neurotoxicity
- - Abdominal pain
- Related to the catheter
- - Inability to access port or infuse the drug
- - Leakage of infusate
- - Peritonitis, abscess, bowel injury
- PREVENTION AND MANAGEMENT OF COMPLICATIONS RELATED TO CHEMOTHERAPY
- CATHETER REMOVAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS