Innovative Approaches to Abdominal Cancer: A Deep Dive into HIPEC and PIPAC with Dr. Byrne Lee

In this episode of Scrubcast, host Rachel Baker speaks with Dr. Byrne Lee, a clinical professor specializing in surgical oncology at Stanford University. Dr. Lee shares his personal connection to cancer, discussing how family experiences have shaped his dedication to the field. The episode delves into innovative treatments such as Heated Intraperitoneal Chemotherapy (HIPEC) and the emerging technique of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC), highlighting their roles in treating cancers that have spread to the abdominal cavity. Dr. Lee emphasizes the importance of a patient-centered approach in cancer care, offering insights into the evolving landscape of treatment options and the crucial role of multidisciplinary collaboration in improving patient outcomes.

Listeners will gain a deeper understanding of not only the technical aspects of these advanced therapies but also the emotional and ethical considerations that accompany cancer treatment. Through personal anecdotes and professional insights, Dr. Lee inspires hope and resilience in the face of challenging diagnoses.

Link to “Results of the First Phase I PIPAC Trial in the United States: Braving the Storm”

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today we are speaking with Dr. Byrne Lee. Thank you for joining us.

Byrne Lee: Thank you, Rachel. Thank you for inviting.

Rachel Baker: Oh, I am just super excited you said "Yes." Dr. Lee, you are a clinical professor in our division of general surgery, specializing in surgical oncology. Why cancer?

Byrne Lee: I will start first in that it's personal. Many people in my family affected by cancer. Sorry. My grandmother, My own mother, three of my aunts so it's a personal battle and a fight against it.

Rachel Baker: I'm so sorry.

Byrne Lee: But when I was going through surgical residency, basically the idea of surgery made sense. You went to the operating room, got a patient through an operation, made them better. You probably never saw them again after [00:01:00] a month or two. I noticed with the cancer patients though, it was more than that. The surgeons that were taking care of cancer, you saw the patient in continuity and you would see them, even if you weren't operating, you were helping manage some of the treatments, some of the side effects, and even.

Unfortunately, at the end of some of these patients' lives, you're still with them, helping them palliation, anything that might be helpful. And this really struck me and I think as time went on, as a resident you get into the science behind cancer and all this made sense. And, thankfully it's been my career for almost two decades now.

Rachel Baker: Wow, I did not know that about you. Thank you for sharing that with me and with the listeners.

So the reason I brought you on the show is hip e so for our listeners, that is Hotel India, Papa Echo Charlie, and it stands for Heated Intraperitoneal [00:02:00] chemotherapy, which I mean. Once you really break that down, it really is what it sounds like.

Would you like to explain to our listeners what it is that you're doing and why it's fondly known as the Shake and Bake?

Byrne Lee: Yeah, so HIPEC, or as you put it, heated intraperitoneal chemotherapy, it's actually part of a treatment that we use for patients who have spread of their cancer to the abdominal cavity and most people see it as or are called peritoneal carcinomatosis, pc.

It is part of the treatment. I say because the first part of it that most people drop off is this idea is cytoreductive surgery or debulking surgery, as most people call it. Some of my patients even call it the “mother of all” or MOA surgery. And it's true. This is an operation where we go in and painstakingly remove every visible deposit of cancer, and at the end of the day, look at the operative field and if everything is clear and without gross evidence of disease, you have to think there's some [00:03:00] microscopic stuff remaining. The idea of putting chemotherapy in the abdomen is not new.

It really has been around for a while, and I think as time has gone on and our treatments for cancer have gotten better. Surgeons started to use it to augment or to improve the outcomes of our patients, particularly when the cancer spreads to the abdomen. So after the big cytoreductive surgery, HIPEC is added, and this is chemotherapy that's heated to about 41 to 42 degrees centigrade.

So, it's a high fever, about 110. And we perfuse it for 90 minutes to two hours and then we drain it.

Rachel Baker: I don't think I realized it was that long.

Byrne Lee: Yeah, it's a pretty long day in the operating room, and we comically call it the shake and bake because at for two hours someone is at the bedside agitating the abdomen, making sure that there's good circulation of the chemotherapy.

So again, shake’n’ bake, as time has gone on. [00:04:00]

Rachel Baker: Why would you put the chemo directly into the abdomen? Why wouldn't you just do it the regular way with the IV?

Byrne Lee: There are some thoughts that the reason why patients with peritoneal or abdominal spread of their cancer don't do as well is that when we give the chemotherapy by vein, not a lot of it actually penetrates or gets to these tumor cells cancer cells.

So at the time of a debulking surgery, or even if we're not debulking, let's say we're just trying to treat patients with intraperitoneal chemotherapy. The idea is that the direct contact and the sort of perfusion of the chemotherapy to these cells is the helping aspect of, or what really drives the kill of these cancer cells.

And again, it has lasted the test of time. Looking at ovarian cancer, colon cancer, appendix cancer, mesothelioma. Many studies and many iterations of studies have shown that, you get the right patient, you get the right setting, using intraperitoneal chemotherapy can often help [00:05:00] these patients survive longer or possibly survive without that cancer coming back in the abdomen.

Rachel Baker: So you mentioned that these cancers that are in the peritoneum, They don't start there. They're all metastatic? They all come from other places?

Byrne Lee: A majority of them are metastatic, so the big ones, ovarian cancer, colon cancer, appendix cancer, most of the GI tract, which is what? Surgeons in the Department of General Surgery deal with are metastatic. Certain ones that we call mesothelioma, we tend to say, come from the lining of the abdomen or the peritoneum itself.

It's a very rare disorder. We do see a lot of it here and it is one of our research endeavors, but that's one of the few that I would say is what we call primary peritoneal cancers.

Rachel Baker: Got it.

Byrne Lee: Yes.

Rachel Baker: So HIPEC was featured on a recent episode of Chicago Med, which like watching television as research is my favorite thing.

They talk about it as a [00:06:00] procedure of last resort. They were buying this patient a few weeks at most. It was very dramatic, but is that reality? Are we really buying them only a couple weeks or do we see outcomes that are better than that?

Byrne Lee: Yeah. I will say that is a bit of a dramatization if you think about it, a surgery that takes six to eight hours plus and in chemotherapy and time in the hospital.

I would say most surgeons and patients would not do this if it was only buying three weeks of life or that much, the internet and television, media, there are good and bad things that come out of it and I always tell my patients like, you don't always take these letters of advice from other people as well.

There are plenty of good sources on the internet and in the media. We see HIPEC or cytoreduction and HIPEC as a treatment. We do see patients who are successful in this operation get long-term survival. I would say my longest patient [00:07:00] has now 17-year survival with a cancer that was supposed to take his life within a year or two.

Rachel Baker: That's fantastic.

Byrne Lee: Yeah it definitely is there. Patients can get a good result from it. Having said that, yes, obviously you are dealing with aggressive cancers at stage four, what we call metastatic. And the reality is even with a big surgery like this, a lot of these cancers come back, but we always talk about.

Cancer care really changes at a remarkable pace. And yes, when I first started surgery, we had three chemotherapies for colon cancer. Now, I can't even rattle off all of them. Exactly. Yeah. Three. So now I can't even rattle off all of them that are on the guidelines. It's just so many, and the treatments are rapidly evolving.

So I do think the strategy of multidisciplinary care. Is what is driving the survival behind these patients. And, even when people believe they've [00:08:00] got a devastating death sentence, oftentimes if you get the right consultations and you seek the right help, you may find that there are more treatment options than you think.

And I, I think that's important for. Patients and people out there to understand. Obviously no one wants to hear the C word and I get it personally too. But it is the, you have to find the right people to help you and treat you at that point in your life.

Rachel Baker: Absolutely.

Byrne Lee: Yeah.

Rachel Baker: So let's talk about the evolution of cancer care. The new kid on the block, not the band, is PIPAC that's Papa India Papa Alpha Charlie. For those at home. And it's not really that new actually. It's been around in Europe. I was researching - it's been over a decade there. And you ran the first phase one PIPAC trial in the US back in 2023, or at least that's when the results came out. Is that correct?

Byrne Lee: I wanna wish I said [00:09:00] ran it. But I had left, there was a change in my career path and I left that institution to come to Stanford. So unfortunately I didn't get to do the first run of that exactly.

But I definitely helped in that. And my partners at that institution ran that trial very well and I'm happy that. It started to get published, and as you said it, it came out in 2023. The first US experience, as you said, I mean it, it's pressurized, intraperitoneal, aerosolized chemotherapy.

Rachel Baker: Yeah. I saw it in the OR with you, and it looked like. If you imagine chemotherapy coming out of a hairspray can,

Byrne Lee: Yes, it's a way to deliver chemotherapy directly into the abdomen to try to treat these peritoneal cancers. The difference between pec and hip is that PEC is really trying to. Reduce the burden of the cancer.

You're not doing the concomitant cytoreduction or the [00:10:00] simultaneous debulking. All you're really doing is taking a look inside with the camera, the laparoscope, doing biopsies to ensure things are going okay, and then delivering chemotherapy. The benefit of that is one, you're allowed to. Real time assess what's happening to these cancers.

So you're going back, each time when you're delivering the chemotherapy, you're looking at it, getting pictures, taking biopsies. So that's real time data for the oncology group. The aerosolization and the pressurized chemotherapy. The idea is that by aerosolizing it goes to a lot more places, pressurizing and allows you no more shaking.

Pressurizing. It means that it, maybe it drives a little bit deeper into the cells, and in Europe they even use electrostatic principles to try to drive it even deeper into these cancer cells. Oh, so it's interesting in that a simple concept like that improves the contact of the chemotherapy to these cancer cells.

Again, at this point, it's essentially an outpatient surgery. Patients go [00:11:00] home either the day of or the following day. We see them again. They can continue chemotherapy as well. So there's no sort of huge stoppage of care. And again I think the results are still coming. We're unsure of what is really gonna happen.

In Europe, as you said, it's been over a decade. It seems to be good as a palliative type of treatment. Patients do live a little bit longer without symptoms. Potentially, about 15% of them may actually. Be converted to have that bigger hip tech operation. It has been a labor of love for me.

You may know, like I have that picture 10 years ago I was in Germany and looking at it and learning from them and trying to bring it to the US and there were a bunch of us that went there that first time and grateful that it's finally showing up here in the US and there aren't a lot of centers just yet doing it.

And we at Stanford have started the endeavor. We're gonna eventually have a clinical trial open. Right now we're doing it as a registry and delivering that part of care for patients here.

Rachel Baker: Why [00:12:00] do you think it's been such a slow catch on?

Byrne Lee: Yeah, I think one, this idea of regional chemotherapy, so putting chemotherapy into different cavities is not something well received here in the United States.

As I talked about it, like you go on the internet and you look up HIPEC, you'll find maybe 75% of 'em say this is a good thing. And then 25 will basically say, this is the devil's work. And this includes even medical oncology and radiation oncology. A lot of people have this bias against putting chemotherapy in places that are not traditional.

So this is a little different in Europe and in other countries. I think certainly the Europeans are much more adept at adapting this and they, they've taken it to a different extent. I think the problem is you're dealing with a patient population that has a pretty poor outcome to begin with, and particularly at that point of the cancer treatment they may have seen.

Two or three different lines of chemotherapy, been on multiple clinical trials, may have had two or three [00:13:00] operations. Yeah. So it's hard to look at this treatment modality and say that this is gonna be the next best thing. But again, you have to look at it in a different way, like patient point of view.

If they're quality of life improves, if they're in the hospital less, if they have less ascites, which means fluid is building up at a slower pace and they don't have to come to the clinic and get drained. I think these are wins and I think as physicians and oncologists we have to understand it.

That's a completely different part of medicine that we just are not used to. We're so used to looking at CT scans and saying, oh, it dropped by two millimeters. It must be working. You're never gonna see that with these patients and there's a different level of result that I think PAC can achieve and it's just understanding that and doing the trials we have to just do it smart and I think that's.

A lot of the centers are starting to come together and really formulate a good plan.

Rachel Baker: I think that it's reminds me of something Dr. Dirbas said on our [00:14:00] show a couple months ago about how we look at a lot of studies and we focus on the outcomes instead of on the journey.

Byrne Lee: Absolutely.

And then I think again when, perfect case and what I talked about in the beginning and why I became a surgical oncologist is you're not just here to do the operation. You have made a contract with this patient and you're gone to stay with them from time you see them to potentially the time that unfortunately things are not going so

Rachel Baker: Well, I could talk about HIPEC and PIPAC all day, but that sound means that it's time for our lightning round. On each episode of Scrubcast, we ask each of our guests the same three questions, and the first one is. Who is a surgeon you admire and why?

Byrne Lee: Yeah, this is a hard one. I have had many people in my life who have inspired me, taught me, and I, I'm like, education is my thing.

I'm all about bringing up the next generation of surgeons. [00:15:00] I would have to say one of my chairs when I was in Los Angeles, his name was Bruce Stabile. I think many people will say, this is the gentleman surgeon. He was the chair at a institution called Harbor, UCLA. He trained generations of surgeons and you talk about the person that could do everything.

He did cancer surgery, he did thoracic surgery. He did vascular surgery, and he was good at everything. Wow. On top of that, he was a leader. He taught me a lot of leadership skills. Sitting in a room, listening to people, talking to people. Like he, he would literally say this is how you handle this person.

And he is don't let that person get in your way. You have an agenda, you have to push it through. And he was. That type of life coach to me. As I said, not just in the operating room, but administratively, he would teach me lots of things and it's sad that he passed of unfortunate cancer.

So again, oh gosh, a lifelong mission. But again, I think as I mentioned, he'd left a generation of surgeons that [00:16:00] carry his tradition and carry his teaching. So he is definitely one of the greats.

Rachel Baker: That's wonderful. The second question is. What is the best advice you have received in 10 words or fewer?

Byrne Lee: I chose, “remember the why.”

Rachel Baker: Oh

Byrne Lee: yeah. So I don't know who told this to me, and it probably came up at least many a few times in my training, but I think we get caught up in the rat race. Many of us, and especially in academic surgery, everyone wants a title. Everyone wants to be chief chair, whatever.

And or have a million letters after their name and. Obviously though that's important, right? I think somebody has to lead, somebody has to be the person who gets the department or division through things, but I think some people lose sight of. It's not about gaining those letters, it's about why did you do this?

Was it because you wanted to be a basic science researcher and develop the next treatment for [00:17:00] patients, whatever disease it is? Was it because you wanted to treat people who couldn't afford care or, for me, again, people who have cancer, terrible diagnosis and really wanted to carry that through, it's very easy to get caught in the rat race.

I would advise young doctors, surgeons whatever you're gonna be: you have to remember why you're doing this. It's the most important part.

Rachel Baker: And I would add to that, that you have shown great leadership even without a title, just by being you. Our third question is, what is your preferred or music.

Byrne Lee: I prefer classic rock.

Rachel Baker: Ooh. Yes.

Byrne Lee: Yes. I grew up in the seventies and early eighties, and so a lot of, I would say Eric Clapton cream are my big music inter, influences. I think you'll find that if you come to my operating room though, I usually will let whoever's there dictate the music.

Because for me, like I just love all music altogether [00:18:00] except country. But there's a reason for that. I've made the cross-country drive at least four times in my life and there's a big part of middle of America that no matter where you are, the only radio station out there is country.

And so it's tough. And that's why I. I can't listen to it for long periods of time. But yeah I'll listen to anything. I love music in the OR.

Rachel Baker: that concludes our lightning round. Before we go, I wanna ask one final question. What is next for Dr. Byrne Lee?

Byrne Lee: Yeah, so as I mentioned, I think the PIPAC saga continues.

Okay. And I'm hoping to continue that aspect and look at clinical trials and open clinical trials for that. As we have quite a bit of new faculty in surgical oncology. It is great for me to watch their careers grow and blossom and I'm happy to not be the person that actually has to run what they're doing, but I'm [00:19:00] helping them and contributing with them.

And again I think a lot of exciting things for our section of Surge Onc. And I think. A lot of good things to come.

Rachel Baker: Agree.

Byrne Lee: So look out.

Rachel Baker: I'm excited to see how this saga unfolds. It has been such a pleasure chatting to you. Thank you so much for coming on the show.

Byrne Lee: Yeah, thank you.

It's been a long time coming, and again, thank you for inviting me. It's been fun.

Rachel Baker: And thank you to our listeners for tuning into this episode of Scrubcast. Until next time, stay sharp.

And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts.

Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds, and our chair is Dr. Mary [00:20:00] Hawn.