Introduction

Peritoneal carcinomatosis—the spread of cancer cells throughout the peritoneal cavity—represents one of the most challenging scenarios in oncology. Patients with malignant ascites (abnormal buildup of fluid in the abdomen containing cancer cells) often experience significant discomfort, reduced quality of life, and limited treatment options. Traditional intravenous chemotherapy frequently yields suboptimal results due to poor penetration into peritoneal tissues, while conventional intraperitoneal chemotherapy has been associated with significant complications and uneven drug distribution.

In this context, Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC) emerges as an innovative approach, designed to overcome these limitations. This case study discusses the successful implementation of PIPAC therapy at Burjeel Holdings—a pioneering achievement as one of the earliest applications of this technique in the United Arab Emirates.

Understanding PIPAC Therapy

Mechanism of Action

PIPAC represents a significant advancement in the delivery of chemotherapy for peritoneal carcinomatosis. The procedure involves several key components that distinguish it from conventional treatments:

1. Aerosolization: Rather than using liquid chemotherapy, PIPAC converts the anticancer drugs into a fine aerosol spray consisting of micro-droplets.
2. Pressurization: The aerosol is delivered under pressure (approximately 12 mmHg), enhancing tissue penetration through physical principles.
3. Minimal Access Delivery: The entire procedure is performed laparoscopically through just two small incisions, minimizing surgical trauma.
4. Homogeneous Distribution: The aerosol format allows for more even distribution throughout the peritoneal cavity compared to liquid.
5. Enhanced Tissue Penetration: The combination of aerosolization and pressure results in deeper penetration of chemotherapy agents into tumor nodules.

Advantages Over Conventional Approaches

PIPAC offers several potential benefits compared to traditional intravenous or intraperitoneal chemotherapy:

• Improved Drug Delivery: Enhanced penetration into peritoneal tissues by a factor of 3-4 times compared to liquid solutions
• Reduced Systemic Exposure: Lower doses with minimal systemic absorption, resulting in fewer side effects
• Repeatable Procedure: Can be performed multiple times at intervals of 6-8 weeks
• Minimally Invasive: Outpatient procedure with rapid recovery
• Visual Assessment: Allows direct visualization and biopsy of peritoneal disease during each session
• Quality of Life: Typically associated with less toxicity and better preservation of function

Current Applications

PIPAC is primarily indicated for patients with peritoneal carcinomatosis arising from:

• Gastric cancer
• Colorectal cancer
• Ovarian cancer
• Peritoneal mesothelioma
• Other malignancies with peritoneal dissemination

It may be employed in various clinical scenarios:

• As palliative treatment for symptom control
• In combination with systemic chemotherapy
• As neoadjuvant therapy before definitive surgery
• For patients who have progressed on conventional treatments

Case Presentation

Patient Profile

A 72-year-old female patient presented to Burjeel Holdings on March 11, 2024, with a history of:

• Carcinoma of the stomach with malignant ascites for several months
• Previous emergency surgery (laparotomy with subtotal gastrectomy) for a perforated gastric ulcer due to malignancy
• Recurrent ascites requiring multiple drainage procedures (three paracentesis procedures within two months)

Disease History

The patient’s oncological journey began with an emergency presentation of a perforated gastric ulcer that was discovered to be malignant. The initial surgical intervention on March 22, 2024, in her home country included:

• Laparotomy
• Subtotal gastrectomy for perforation and peritonitis
• Roux-en-Y gastrojejunostomy performed with palliative intent

Intraoperative findings included:

• 1×1 cm perforation in the anterior wall near the gastric antrum
• Large neoplastic lesion along the lesser curvature
• Suspicious desmoplastic areas on the posterior wall of the stomach
• Enlarged lymph nodes
• Suspicious malignant-appearing deposits on the root of mesentery

Histopathology

Pathological examination of the surgical specimen revealed:

• Poorly differentiated adenocarcinoma of the stomach with perforation
• Positive lymph node involvement (1 out of 10 nodes)
• Positive immunohistochemistry markers: CK20, CDX2, CK7
• Negative synaptophysin

Previous Treatment

Following surgery, the patient received systemic chemotherapy:

• 12 cycles of CAPEOX regimen (capecitabine and oxaliplatin)
• Completed the full course

Despite this comprehensive treatment approach, the patient developed progressive abdominal distension due to recurrent ascites. This necessitated therapeutic paracentesis (fluid drainage) on three separate occasions within a two-month period, with approximately 3.5 liters of fluid removed during each procedure. The frequent need for these interventions significantly impacted her quality of life and functional status.

Clinical Assessment

At presentation, the patient reported:

• Progressive abdominal distension
• Discomfort and limited mobility
• Decreased quality of life due to frequent paracentesis requirements

Diagnostic Evaluation

Recent investigations included:

MRI Abdomen (February 23, 2024):

• Persistent abdominopelvic ascites
• Omental-peritoneal nodularity and strand changes
• Clumped small bowel loops without frank obstruction
• Normal-appearing liver

PET-CT Scan:

• Moderate ascites
• Mildly thickened peritoneal reflections
• Stable non-avid right adrenal adenoma
• Stable non-avid pancreatic cyst

Tumor Markers:

• CA 125: 7.2 U/ml
• CA 19-9: 30.75 U/ml
• CEA: 2.39 ng/ml

Treatment Decision and Implementation

Multidisciplinary Assessment

The patient’s case was evaluated by a multidisciplinary team including:

• Dr. Mohammed Basheeruddin Inamdar (Specialist Surgical Oncologist and Robotic Surgeon)
• Dr. Prasanta Kumar Dash (Specialist Medical Oncology)
• Dr. Mehdi (additional team member)

After comprehensive review of her clinical history, imaging studies, and consideration of available treatment options, the team proposed PIPAC as an innovative approach to address her recurrent malignant ascites.

Rationale for PIPAC Selection

Several factors influenced the decision to proceed with PIPAC:

1. Failure of Conventional Therapy: Despite completing 12 cycles of systemic chemotherapy, the patient had developed progressive peritoneal disease with recurrent malignant ascites.
2. Symptom Burden: The need for repeated paracentesis procedures (three times in two months) indicated significant symptom burden and quality-of-life impact.
3. Localized Disease Control: The patient’s disease appeared predominantly confined to the peritoneal cavity, making a local-regional approach appropriate.
4. Age and Performance Status: At 72 years, the patient would benefit from a less toxic, minimally invasive approach rather than aggressive systemic therapy.
5. Therapeutic Goal: Palliative management focused on symptom control and quality-of-life improvement aligned well with PIPAC’s capabilities.

Procedure Details

The PIPAC procedure was performed under general anesthesia using minimally invasive techniques:

1. Access: Two small keyhole incisions (5mm and 12mm) were created for laparoscopic access
2. Assessment: Diagnostic laparoscopy was performed to visualize the extent of peritoneal disease
3. Preparation: After evacuation of ascitic fluid, the abdomen was inflated with carbon dioxide to create a pneumoperitoneum
4. Aerosolization: Chemotherapy drugs were aerosolized using a specialized nebulizer (CapnoPen) connected to a high-pressure injector and delivered into the peritoneal cavity
5. Exposure: The aerosol was maintained under pressure within the peritoneal cavity for a predetermined period to allow optimal tissue penetration
6. Evacuation: Following the treatment phase, the aerosol was safely evacuated through a closed filtration system
7. Closure: The small incisions were closed, completing the minimally invasive procedure

The entire procedure was completed as a day case surgery, with the patient discharged the same day after recovery from anesthesia.

Significance and Innovation

Regional Context

The implementation of PIPAC therapy at Burjeel Holdings represents a significant milestone in advanced cancer care in the region:

• Believed to be only the second case of PIPAC therapy performed in the United Arab Emirates
• Demonstrates the institution’s commitment to adopting innovative approaches for challenging oncological scenarios
• Expands the therapeutic options available to patients with peritoneal carcinomatosis in the region

Institutional Capabilities

The successful implementation of PIPAC therapy highlights several key institutional strengths:

1. Advanced Facilities: The procedure requires specialized equipment and technology available only at comprehensive cancer centers
2. Specialized Training: Surgical oncologists performing PIPAC require specific training and expertise in the technique
3. Multidisciplinary Approach: Collaboration between surgical oncology, medical oncology, and supporting specialties is essential for patient selection and management
4. Comprehensive Care: Ability to offer advanced palliative interventions represents an important component of complete cancer care

Clinical Implications

Patient Selection

PIPAC therapy is particularly beneficial for:

• Patients with peritoneal carcinomatosis from gastric, ovarian, colorectal, or other GI malignancies
• Those with recurrent malignant ascites requiring frequent paracentesis
• Individuals who have progressed on systemic therapy
• Patients seeking minimally invasive palliative options with low morbidity

Integration with Standard Care

PIPAC can be integrated into comprehensive cancer care in several ways:

• Palliative Setting: For symptom control and quality-of-life improvement
• Combination Approach: Alongside systemic chemotherapy for enhanced disease control
• Sequential Therapy: As part of a multimodal treatment strategy
• Clinical Trials: Within research protocols to establish optimal protocols and outcomes

Practical Advantages

From a practical perspective, PIPAC offers several important advantages:

• Day Case Procedure: Minimal hospitalization requirement
• Minimal Side Effects: Reduced systemic exposure compared to IV chemotherapy
• Repeatable: Can be performed multiple times as needed (typically every 6-8 weeks)
• Assessment Opportunity: Allows repeated visual assessment of treatment response
• Tissue Acquisition: Facilitates biopsy for molecular and histological evaluation

Future Directions

Ongoing Research

The field of PIPAC therapy continues to evolve, with several areas of active investigation:

• Optimization of drug selection and dosing
• Development of novel aerosolization devices
• Combination approaches with immunotherapy
• Personalization based on molecular profiling
• Expansion to additional tumor types

Institutional Development

Burjeel Holdings’ successful implementation of PIPAC therapy represents an opportunity for:

• Development of a specialized peritoneal malignancy program
• Participation in international collaborative research
• Training and education of additional specialists
• Expansion of treatment access to more patients in the region

Conclusion

The successful implementation of Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC) at Burjeel Holdings demonstrates the institution’s commitment to advancing cancer care through innovative approaches. As one of the earliest applications of this technique in the UAE, it represents an important addition to the therapeutic armamentarium for patients with peritoneal carcinomatosis and malignant ascites.

PIPAC offers a minimally invasive, repeatable approach with enhanced drug delivery to peritoneal tissues while minimizing systemic exposure and side effects. For selected patients, particularly those with recurrent malignant ascites requiring frequent paracentesis procedures, PIPAC may provide improved symptom control and quality of life.

The multidisciplinary approach employed in this case, combining surgical oncology and medical oncology expertise, highlights the comprehensive cancer care available at Burjeel Holdings. As experience with the technique grows and research continues to refine protocols and applications, PIPAC therapy is likely to play an increasingly important role in the management of peritoneal malignancies.

Experts