This is Roswell. Rookie by Roswell Park Cancer Institute. European opinion or your total options. Your host Tammy -- and welcome back to Roswell incident continuing conversation about all aspects of cancer care diagnosis. Treatment and research from a comprehensive source -- that would be Roswell park. Cancer institute right here in buffalo new York and good morning I'm too -- -- in today. We're gonna really get into it we're gonna talk about something that is at least from my perspective and I think yours too pretty high tech and it's called. Hi tech and you were gonna understand -- and about thirty minutes or so doctor John McCain is with us today. Chief of melanoma and sarcoma service here Russell park Doctor King thanks for being here thank you for having -- I appreciate your time and doctor Joseph. -- -- Is with us today he is an assistant professor in the department of surgical oncology and an associate member in that department of immunology doctor skits he welcome to the the Roswell in the studio good to be here appreciated early morning and no. Hype that I'm not even going to. Tried to say it Tony what it is. Well basically it stands for hyper farming and prepare to -- chemo profusion and and me. Sort of simplistic way it's focused chemotherapy so we have patients that have isolated spread of their cancer to -- the cavity. Would be appendix cancers colorectal cancer means that the glioma. And what we do as we would go in and surgically remove the tumor down to minimal or no disease. And then follow with a one time intra operative treatment of -- -- heated chemotherapy. So we're -- chemotherapy up to a bad fever about a 104 degrees. Very high doses of chemo but most of it stays in the belly so there's very little absorbed into the circulation. We basically kind of circulate that around almost like back -- a radiator or an aquarium filter for usually 9220. Minutes. Wash and I'll put all the connections back together so it's really a one time focused high -- heating chemotherapy treatment. For patients with isolated spread their cancer to the linings of their abdomen doctor kitty -- -- you know you're you're thrown around in terms here I've met a lot of -- -- -- -- -- -- to -- You know the area we're talking about. So the -- to -- cavity is the inside of your abdomen so think about your intestines and your organs being the furniture in a room and the -- -- -- the room so it's all the space around it. Many cancers of the GI tract. Colorectal appendix gastric cancer pancreas cancer. Will break through the wall of the organ where they developed and still little cells into the -- you cavity. And then much like getting a dandelion on your lawn they made little ceilings they float around in there they land they grow they continue to. Just basically propagate all through the -- -- cavity. This is the sort old wives' tale that they opened up grandma and the air got into the abdomen and then the three months later she cancer -- -- you cavity. It was not that the air did it it's that twenty to 30% of all GI cancers will spread this way so it's actually not an uncommon phenomenon. We just started here you know recognizable of an earlier stage now that we have things like CT scans and like opera -- and things like that. How how does this all happening -- if -- -- can explain the process for me. So if we have a patient is appropriate candidate and we can talk about some of the criteria that would make somebody an ideal candidate this is clearly not for every patient with what we call carcinoma tells us. For some of the appendix tumors there's a term we can talk about only two calls to -- some pair -- -- I. Which we tend not to use but it's a little reviews and this tumor that builds up in the -- you cavity. But if doctors get skier myself for one -- the other surgeons that does this doctor Francis cutie. He's a patient we assessed them their appropriate candidate basically we take them to the operating room and the first thing we do is make a very small incision to look around. One of the most important. Aspects of this is the ability to remove almost all are all of the tumor. I tell the patients that -- chemotherapy does not work like -- what does not dissolve all the cancer that's in there. It actually works more like stain if you staying aboard it sinks and a little bit but it doesn't come out the other side of the two by four. So the ability to get the total amount of cancer down to the least possible amount. Is actually the factor that gives you the best chance of responding to the heating chemotherapy. So often spend several hours of the patients a candidate removing. Parts of the GI tract if they're involved the ovaries the momentum. Really just trying to clean up every little tumor nodule very much like -- a bag of rice in your kitchen and it takes awhile to get everything cleaned up. -- once that's complete we actually put some hoses -- canyon was into the abdominal cavity. We temporarily close the skin and then we basically fill up the -- -- cavity with fluid. And then there's a machine that pumps that around to get three heated we heated up to the target temperature. And once everything stable there's no leakage that that the temperatures were wanted to be we -- the high doses of -- now. And then basically we circulate that around again for about an hour and a half to two hours. We're actually gently massaging the abdomen while we do that and that's where this procedure got it's nickname to shake and -- so you're constantly shaking. You've got this high dose chemo. Once it's finished you rents everything now you take out the -- you open the patient back up if you have to make any connections you do that at that time. And then you close the patient so the shortest ones may -- 67 hours if you count the -- time of putting things back together. Some of them with more extensive tumor can actually be twelve or fourteen hours for them the length of the entire operation. -- twelve to fourteen hours yes well OK with the doctors -- -- this is it relatively new. I mean we're talking 2003 procedure right. Yes yes and no I mean there's some aspects of this procedure that have been done for decades. Could do for ovarian cancer and you know it common. Procedures to -- of the tumor this is adding a little bit more in treating different type of cancer. But the great news is the outcome. The outcome has been phenomenal here in -- patience that the outcome is significantly better then. Historic treatments that we can pass in the pass these patients received systemic chemotherapy. And there really was not as effective. I'm in this group of patients. So that. You know very few patients would be alive at five years with this procedure however and and good patient selection. You may see up one out of three patients achieve secure depending on the type of cancer. For certain cancers it's even better for music studio the numbers are are significantly higher and become the gold standard for that disease process. You know we hear so much you know on TV if you watch TV you see so many you know -- so neatly Obama. Advertisements and you know you know how to treat. So I mean this is really this is a procedure that is his you know is good for that. Right I mean William music film. And when you when you see those commercials on TV the most the time alone and but you can honestly it was so -- -- film of the -- him and our primary parenting always a feeling Obama. Is Israeli treatable by this procedure as a matter of fact some of these treatments they're looking for a for the long nowadays. Involve giving chemotherapy to the cavity itself after removing the disease. Okay chemotherapy. Through the ID which I think you know many many of us understand what what that that is and how it works this is this is different this is completely -- Drugs. -- things in your bloodstream do not get very high concentrations in the appear to need him. Things you've put into the parent you cavity tend not to get in your bloodstream so that's one of the reasons that we. For some patients that kidney failure said of getting you know dialysis three clean the blood they get a -- put into their parent you cavity. And constantly you know what we call -- fluid in and out. Getting rid of the poisons from the -- but much of the fluids staying there. So we're taking advantage of the fact that the cancer is in the pair to neo cavity that's where we want the high doses of team out ago. But we don't -- poise and the rest of the patient so getting IV chemo. You lose your hair you get little blood counts you feel sick to your whole body just to get a little bit of -- into the parent AM. Here we're kind of dumping the high doses of chemo right -- -- ago. And one of the things that's true with chemotherapy the more you give the -- works. The problem is that the patient has always paying a price in terms of side effects and toxicity so. By giving very very high doses two or three times the dose we could give intravenously right into the -- -- cavity. It's going right where it needs to be and probably less than 20% of patients won't even get temporarily low blood counts. People typically do not lose their hair so you're taking advantages of high doses of -- without hurting the rest of the body. Is there a lesson here. With other you know -- we've. Talk specifically about you know where this tight pack you know where you can target -- -- -- you don't disease there you can target. Is there a lesson moving forward to other diseases. -- -- -- of cancer. Some people wonder why the melanoma sarcoma service does say hi tech when we -- most of these are GI cancers actually our service like this gets you myself and doctor Francis cutie. How we're actually that surgeons who do regional therapy so this would fall into what we call a regional therapy. -- to your question there are some patients with isolated melanoma that starts the track up the -- legs kind of marching -- with multiple little implants. And we do a similar thing that we take the patience -- the operating room put their arm -- leg on bypass. Isolated from the rest of the body and don't very high doses of -- directly into the armor lake circulated around rinse that out so again it and we heated up at the same time. One of the interesting things about key is your normal cells if things get too hot they can kind of shut down. They have some mechanisms where they can protect themselves weather the storm. Once the temperature goes back to normal though sort of come back online. Many cancer cells lack those mechanisms so when their heated up they may die just from the heat. So although some of this heating is due to -- we're trying to -- drive more chemo into the tumor cells. The heat alone may actually be killing some of the tumor and we know from a lot of historical studies -- high -- at the higher the temperature. The better the killing of the tumor but then you start to get more side effects or toxicity to the patience of the temperatures that we use 42 degrees Celsius. About a 104 degrees Fahrenheit. It's sort of striking a balance it's hot enough to hopefully kill the tumor with a lot of injury you can accomplish that -- did community that's fascinating to me that the temperature thing. It's actually. There it's a lot of technical devices there's a pump that circulates the fluid and a very high rate up -- you know leader a minute or more. And then we have some specially designed heating machines that. Sort of is the fluid goes by that the fluid and in the heater is not actually communicating with the fluid in the patient. But the -- sort of -- together with appear in between. And basically while the patients in the operating room. Especially since they're asleep you can imagine I could not keep you up to a 104 degrees when you were awake and be very comfortable. So because the patient's sleep in the opera Arum it's very easy to control the temperature and and basically just get these very high temperatures in the parent -- cavity. Again one of the advantages that patient. Themselves are not really getting all that -- we typically don't go over 39 degrees for the rest of the body. But we're getting 34 degree difference in terms of. The temperatures in the appear to -- Truly amazing stuff this is Roswell is that is doctor John McCain. He is the chief of melanoma sarcoma service here Roswell park. And -- also with us today is doctor Joseph -- ski he is an assistant professor in the department of surgical oncology. In an associate member in the department of immunology -- gets hot these patients do that -- I mean we're talking along procedure yes scandalous it's. That is an extensive procedure. Like doctor came in mentioned the course the surgery itself can be anywhere from seven hours to quick case out to maybe fourteen plus hours. And the recovery time. We typically tell patients are going to be in a hospital for a roughly two weeks most patients actually get discharged home between round date ten -- so. We look at our numbers. But we televisions -- possible two weeks and the main issue is recovery GI function. So when the bells when you do all this manipulation and when you give that he chemotherapy. The -- take awhile to come around -- small test and takes a while the -- takes awhile to come around and function properly. So most patients we'll have a nasal gastric tube. And we keep that in -- of wells function and usually that happens around age eight or nine or so. Another thing that we keep an eye out for us going get this heating chemotherapy alone has very little side effects. One side effects as they can lower the white counts so we do follow the White House make sure that there are okay. In very rarely do we ever have to give anything to treat the white counts. I'm so -- the patients do recover it's about a fourteen day hostels anywhere from ten to fourteen days. And after that we tell in the Q a that we use. We know that it added new gives some fatigue and so patients are. You know still not back to base until about six to eight weeks after the surgery and then after that. They tended to and to improve -- return -- baseline. What's the patient reaction generally when you when you the with the patient and in the hear about this this procedure. Because so much in medicine today is quick. It's outpatient -- in and now it's it's the -- right you're talking this is in the trend towards us surgeries been minimally invasive this is Maxwell invasive surgery and -- it's a long conversation we you know we said its side about it good hour or so are more. Typically with each patient that's new. To go over all the details we're talking about because it is extensive. People do need to know the risks and the benefits. You know we talk about some of the benefits it offers a shot a cure for certain patience and maybe one out of 31 out of four. But there's still 203 or three out of four patients that we will still select them you know may not get the benefit and so there's there's lots of conversation must. Not only discussing the the you know procedures -- but the perceived outcomes. Crusade so I mean great great great outcomes. Yeah we looked at our data. You know we have had now as a percent you know offered immortality which is is very good. Thirty day -- our -- immortality is zero percents. And you know most of the things we talked of oh really at this procedure is. It's a series of smaller procedures and the risks that are associated with those soon in the the risk in this procedure is. And with any major uncle logic procedure. You know we we worry about blood clots we were about pneumonia as we worry about infections those types of things and we've been pretty good about managing those things -- -- well. Factored -- develop this whole. Program here right. Correct so IE I came to -- 2002 I hit on this -- previous institution -- was and -- it took a little while to get things going as you can imagine it's not something that you say okay we're ready to go let's start. So we're very selective. A lot of there referring medical oncologists and people in our region effect were the only facility in New York State that does this procedure at the present time. We really are wanna be very selective there're there're are probably fifteen senators in the US that did it when Roswell started their program that probably over fifty now. There are several commercially available companies that make these machines. But sometimes places do it just to do it and I think that it which really have to think about it for a person has cancer. Their situation is different than the next -- everybody's situation is unique this is going to be perfect for some patients not perfect for others. So we really just did not want to sort of opened the floodgates just they have everybody come here let's do lots of these. We probably do on average -- -- couple month. And that that fits in very nice because the people that -- selecting forward for having very good outcomes and that's the most important thing how do you prepare for this how does he know I think that you is the position and you as the positions. In the search and how do you prepare and how -- the patient prepare for this type of vote procedure or things for tomorrow for help the patient prepares -- They you know for long people have some concerns about long operations and and I tell patients that. For any operation the most critical components -- when you go to sleep when you wake up that's when you're giving control up of your body and your taking it back. So it's sort of like flying on a plane the take -- on the landing are the two most important parts whether it's a one hour flight in between or eight hour flight. That's sort of the auto pilot. So from that standpoint want it even though it's a long operation with healthy patients they're going to do very very well. That they the only difference is they get a lot of extra fluid because of the length of the procedure and the -- chemo causes -- response we tell the patients for them they're going to go to sleep wake up. They will spend usually about 24 hours in the icu. Be as -- gives -- said because it takes the intestines several days to wake up because of the -- he came out. They will have that you've been there knows the kind of -- up their stomach like a sump pump until. Things come back on line. But for most of -- can be about seven to ten days of not eating. Once they start eating things -- very quickly and again 95%. Or more patients go home by date kind of working eating regular food so. It's there there's a lot of down time at the beginning for the patient's recovery. For us it's just another day at the office in whether you do to seven -- operations 34 hour operations or want -- while our operation. Mentally you're kind of doing the same thing. But when you doctors talk about some pops. And I backed up. It's great analogy though. Doctors kinki. -- -- -- your mind yet through it proceed and that is a long time to have someone's life and people -- asked that frequently you know I'll be honest with -- -- here we -- focused. The time -- line by and you don't really realize it when your focus on what you're doing. You know literally hours to pacify and he really don't notice it in and I think goes back toward training. In surgery as residents. You know we've hold on a variety of different cases similar a lot of cases we -- -- liver transplants go to 1824 hours or so. And you're so focused that he you disks. Here at the task at hand and you know really now's the time passing. Where we go from here -- that you learn. You know your your your very focused on what you're doing today what you're doing to help patients today tomorrow. But -- we go from here I think you -- some some insight from both the view where you think this. Holes I packed it in what you're doing is is going to take us down the road answer with your doctor can. I actually -- doctors -- -- -- because. He has a significant research effort in his laboratory to try to improve this treatment in and take it past. You know we've kind of been doing this the same way now for the last couple decades we don't have very many new drugs. We debate about whether it should be ninety minutes or 120 minutes or 42 degrees or 43 degrees but. I'm sort of what you said that the Grand Slam is coming up with better drugs -- saw a really defer to Joseph because that he's put a lot of effort into. Making those advances are. Your -- so we've our -- has been fortunate to develop several models where we're looking and hi -- the way that we shooting humans try to mimic exactly the way we do and and so that we control the circumstances. And then look and and many really the variables and and look at the outcomes and I think the future for this is looking and you know we talked about targeted agents we talk about targeting the -- -- him. With standard chemotherapy but I think the future will be using agents and take advantage of the hypothermia and that's you know that not only improve the drug uptake but also worked on the cancer cells to make them more sensitive to heat. Or other stress yours and now or we're doing a lot of that work actually a Roswell or some on new drugs have been. Discovered. By several though lab investigators that we've been trying consumer models in the initial lot of promise. So I think that's the future taking not only targeted approach in terms of delivering drugs the parent him by using targeted agents -- take advantage of the divers army. And some of the other unique features of this disease process. And so we're looking at those and you know we're hopeful that some of these drugs and come into clinical try. I'll at some point. And and we're very optimistic about it. You don't. The great thing about having Russell park you know in in these cancer centers. You know there are many of them as you've -- you both well known around the country. Right here in our community is this. This you know high -- this you know up to date treatment plan. You know we're talking about today. This can't be done everywhere. It really I mean this is something that this is a reason why did you know if someone needs to deal with with cancer in her life. Why they should consider a comprehensive cancer center like Russell I I can. Really agree I think it's not only having a surgeon I can do this but it's it's it goes -- -- the beginning and you know having the pathologist reviewed the at the you know to get the -- diagnosis to make sure -- something that we should be treating with this. You know it's the a support system that we have here in terms of you know the anesthesiologist who -- the -- that we're doing knows that the flu chips that are involved and and some of the nuances it's the post op recovery the icu. And the the floors and nursing staff -- knowing what to expect with these patients and knowing how to care for these patients so it's not. Just a surgeon but it slows the whole set -- it's a whole institute and I agree that I think that. Russell does offer that. Duct -- talk about how we get to the point of making a decision that someone is a candidate for this type of procedure. I actually think that is the most critical components for this procedure. If you look at all the available literature the factor that is the most predictive of whether patients can have any response that the heat -- how does -- know. Is the surgeon's ability to remove all or almost all of the -- what we call complete -- a reduction. And some of that as a surgeon variable you know working hard getting rid of it some of it is the biology of the tumor. So it really not all of it is in the hands of the surgeon and and that means that this is clearly not a candidate for every person in this situation is very much like. Impeachment colorectal cancer that has liver metastasis he's not every one of them as a candidate for liver re section. So I tell patients there's actually three hoops they have to jump through to be a candidate for this procedure. The first one is that they're healthy enough to tolerate a procedure of this magnitude. You know -- they their heart has to be good their lungs their kidneys to have a fourteen hour operation you know two weeks in the hospital. So for some patients. You know five heart attacks bad emphysema they're probably not going to be candidate. The second criteria is that they do not have any disease outside the pair Camille -- If we're gonna put blinders on and focus all our efforts treating the surface is if they have spread to their long and spread to their liver spread to their bones. Were ignoring the treatment of those sites so that that occasionally be better served getting IV -- that treats the whole body. And then the last criterion is that we can get rid of all of the tumor and that's why why actually start with a small incision first. These tumors tend to grow like sheets rather than long so there are notorious for being under estimated on the patients cat scanner pesky and it's almost like it's going -- on the floor just kind of spreads out and you don't see it very well from a distance. So we actually look in there and we make a decision right at the beginning can we get rid of almost all are all the tumor if the answer is -- them are actually closed end. Despite the fact I've done this for over ten years seven to 10% of the time you'll get all the way to use the surgery. And we won't be able to do it's what we call a no go and that's the same throughout the world there's -- programs in France and doing it for twenty years. And there are no -- rate is 7%. So if we get in there and we can't do -- -- reduction that sort of the last thing. If CT scans show a lot of disease we know there's going to be more will we get in the what the scans shows. So those are sort of the three features that are very very critical. When we get in there most of the organs are what I call negotiable but some of them aren't so you can live without part or all of your -- you can live without ovaries -- momentum your spleen. Even part of your stomach you cannot live without the blood supply to your liver which is called the -- happen this and that's a place -- tumor often accumulate. And you can only live with a certain percentage of your small intestine that's for you absorb all the nutrition. So if you lose more than say 50% or certain amount. No matter how much you eat you won't be able to absorb the nutrition you are frequent diarrhea. So a lot of times that amount of small ball involvement is that the deal maker deal breaker for gonna have to respect too much small intestine. In the patient won't be a candidate so it's not just quantity of life were actually looking at the patient's quality of life afterwards are they going to be normally going to be able to eat and enjoy food and you know there's no sense living longer if you become an intestinal cripple when you're not able to actually you. Get nutrition from what you mean you've spent a lot more time I think. Planning that you do actually doing great so so it should be that's really you know and I think. We -- the you know just the you know the average person or the patient. I don't think we think of view that way we think you do and I think. You know it's terrific there's so much that goes into what you do every day that there's an all carpentry saying major twice cut once. I think that applies to you complex surgical procedures there. Hero is good for him and I actor came I appreciate your time. Guys thank you so much it's it's unbelievable this this entire procedure that process. And in the results so thank you appreciate it. Great that doctor John -- Is the chief of melanoma sarcoma service here Roswell park. And we appreciate time is always. And doctor coast gets Heath thanks so much for being here thank you appreciate it. Doctors gets he is an assistant professor in the department of surgical oncology and an associate member. The department of immunology here and it Russell park if you'd like to know -- you can always. Visit the website at Roswell park dot. Listen to Roswell this Sunday mornings at 630 young WB yeah. -- by Roswell Park Cancer Institute your -- opinion for your total options on line at Roswell this god of war. And and do you. Then.