Cytoreductive surgery and HIPEC for peritoneal surface malignancies
The peritoneum is the thin lining that covers the inside of the abdomen and the surface of the bowel, liver and pelvic organs. Cancers that start in the colon, rectum, appendix or ovary, and sometimes the stomach, can shed cells that settle on this lining and grow as small deposits. This is called peritoneal surface malignancy, or peritoneal carcinomatosis. It is hard to treat with chemotherapy given through a vein alone, because the drug reaches the lining poorly.
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) takes a different approach, in two parts and during one operation. First, the surgeon removes every visible cancer deposit. Then warmed chemotherapy is circulated inside the abdomen to treat the tiny cells that cannot be seen or removed. Dr. Yogesh Bansod offers this approach to selected patients, especially those with advanced colorectal and ovarian cancers.
It is a major operation and it is not right for everyone. The most important step is deciding, with scans, a laparoscopic or operative assessment where needed, and a tumour board discussion, whether complete removal is realistic and whether you are fit enough to benefit. If it is not the right treatment for you, we will tell you plainly and plan the best alternative.
Conditions we assess and treat
- Peritoneal metastases from colon and rectal cancer
- Advanced ovarian, fallopian tube and primary peritoneal cancer
- Appendiceal tumours and pseudomyxoma peritonei
- Peritoneal mesothelioma
- Selected stomach cancers with peritoneal spread
- Peritoneal recurrence after earlier cancer surgery
- Second opinion on whether CRS and HIPEC is possible
Signs that cancer may involve the abdominal lining
- Persistent bloating or a swelling abdomen
- Fluid collecting in the abdomen (ascites)
- Feeling full after very small meals, or loss of appetite
- Abdominal pain, cramps, vomiting or constipation that suggest a blocked bowel
- Unexplained weight loss and tiredness
- A scan or earlier operation report that mentions "peritoneal deposits" or "carcinomatosis"
- Rising tumour markers such as CEA, CA-125 or CA 19-9 after earlier treatment
Having one of these does not mean you have cancer. It means you should have it checked by a specialist.
How the diagnosis is made
- Review of earlier biopsy, histopathology and operation notes
- Contrast CT of chest, abdomen and pelvis, with MRI or PET-CT in selected patients
- Tumour markers such as CEA, CA-125 and CA 19-9
- Diagnostic laparoscopy in selected patients, to see and score the extent of disease
- Assessment of heart, lung, kidney, liver function and nutrition
- Tumour board discussion with medical oncology and radiology
How cytoreductive surgery and HIPEC are performed
The entire procedure takes place in one operation under general anaesthesia, and it often lasts several hours. It follows these steps.
Assessing the extent of disease
The surgeon examines every region of the abdomen and scores the disease, using the Peritoneal Cancer Index (PCI), a scale from 0 to 39. The lower the score, the more likely that complete removal is possible.
Cytoreductive surgery (CRS)
All visible tumour is removed. This may involve stripping the diseased lining (peritonectomy) and removing the omentum, and, where the tumour involves them, parts of the bowel, spleen, gallbladder, uterus and ovaries. The aim is a complete cytoreduction, with no visible disease or only tiny residual nodules (a score of CC-0 or CC-1).
HIPEC: heated chemotherapy in the abdomen
Directly after the tumour is removed, chemotherapy solution warmed to about 41 to 43 degrees Celsius is circulated through the abdomen for around 30 to 90 minutes. Heat increases the effect of the drug on cancer cells, and the drug reaches the lining at a much higher concentration than is possible through a vein, with fewer side effects in the rest of the body. The drug depends on the cancer, for example oxaliplatin or mitomycin C for colorectal and appendix cancers, and cisplatin for ovarian cancer.
Reconstruction
Bowel is rejoined or, when it is safer, brought out as a temporary stoma. Drains are placed and the abdomen is closed.
Intensive care and recovery
After the operation you are closely monitored in an intensive or high-dependency unit for the first days, with pain control, nutrition support and early physiotherapy. Chemotherapy through a vein is planned before and/or after surgery by the medical oncologist when it is indicated.
Who may benefit from CRS and HIPEC
Outcomes depend more on careful selection than on any single technique. The patients most likely to benefit usually have the following in common.
- Cancer that is confined to the abdomen, or that has only limited disease elsewhere that can also be removed
- Peritoneal disease that scans and assessment suggest can be removed completely
- A cancer that has been stable or has responded to chemotherapy
- Good general fitness, nutrition and heart, lung, kidney and liver function
- A clear understanding of the surgery, and a supportive family
When the operation is usually not advised
Surgery of this size carries real risk, and it is only worth doing when there is a good chance of removing all the disease. CRS and HIPEC is usually not recommended in the following situations.
- Disease through long stretches of the small bowel that cannot be removed safely
- Widespread spread to distant organs that cannot be treated
- Cancer that is growing quickly despite chemotherapy
- Poor general health or nutrition that would make recovery unsafe
What the evidence shows
Colorectal cancer: complete cytoreductive surgery, followed by chemotherapy, has delivered long survival in carefully selected patients with peritoneal metastases. The large French PRODIGE 7 randomised trial found that adding oxaliplatin HIPEC to complete cytoreductive surgery did not extend survival further than surgery alone, so the role of HIPEC in colorectal cancer is still debated. Complete removal of disease is the most important factor, which is why selection matters so much and why we discuss both options with you openly.
Ovarian cancer: in the OVHIPEC-1 randomised trial, women with stage III ovarian cancer who received cisplatin HIPEC at the time of interval cytoreductive surgery, after three cycles of chemotherapy, lived longer (median survival of about 45 months compared with about 33 months) and went longer before the cancer progressed than women who had surgery alone. The benefit was seen in a defined group of patients, and research continues on which women gain the most.
Evidence differs between cancer types and continues to develop. We tell you what is known and what is uncertain for your cancer.
Risks, hospital stay and recovery
CRS with HIPEC is among the largest operations in cancer surgery. Risks include bleeding, infection, leakage from a bowel join, low blood counts, effects on the kidneys and clots in the legs or lungs. These risks are higher than with standard cancer surgery, which is a reason the decision is taken together, with the surgery done in a hospital that has intensive care and blood bank support.
Most patients stay in hospital for around one to two weeks, and sometimes longer. Returning to full strength usually takes several weeks to a few months. After recovery, we follow you with regular scans and blood tests, usually every few months at first.
Treatment options with Dr. Yogesh Bansod
Cytoreductive surgery with HIPEC
Complete removal of visible disease followed by heated intraperitoneal chemotherapy, for selected patients with colorectal, appendix or ovarian peritoneal disease.
Chemotherapy before surgery
Systemic chemotherapy first can shrink disease and show how the cancer behaves, so that surgery is offered to those most likely to gain. Timing is decided with your medical oncologist.
Interval surgery for ovarian cancer
Surgery after about three cycles of chemotherapy for women whose disease could not be completely removed at the outset, with HIPEC in selected patients.
Cytoreductive surgery without HIPEC
When the evidence for HIPEC is weak for your cancer type, or you are not suited to it, complete removal alone may still be the best option.
Relief of symptoms
When surgery is not the right choice, we help with symptom control, including draining abdominal fluid, managing bowel blockage and coordinating chemotherapy.
Cancer care close to home in Thane
Decisions about CRS and HIPEC depend on a detailed review of your scans and earlier reports, and that review can be done at a consultation in Thane before you travel for any procedure. Bring your CT, MRI or PET films, biopsy and histopathology reports, operation notes from any earlier surgery, and your chemotherapy history. We will give you an honest view of whether the operation could help, what it involves and the alternatives.
Frequently asked questions
What is HIPEC?
HIPEC stands for hyperthermic intraperitoneal chemotherapy. After the surgeon removes all visible tumour, warmed chemotherapy is circulated inside the abdomen for a set time. Heat and direct contact help the drug act on remaining microscopic cancer cells on the abdominal lining.
Is cancer in the peritoneum the same as untreatable stage 4 cancer?
Peritoneal spread is classified as advanced (stage IV) disease, but it is not the same for every patient. In a selected group, where the disease can be removed completely, surgery with HIPEC can be offered with the aim of long-term control. Where that is not possible, other treatments can still help.
Does HIPEC work for colorectal cancer?
Complete cytoreductive surgery can give long survival in selected patients. Whether adding HIPEC gives further benefit has been questioned by the PRODIGE 7 trial, so we discuss the evidence with you and recommend it only when it is likely to help.
Is HIPEC used for ovarian cancer?
Yes. A randomised trial (OVHIPEC-1) showed longer survival when cisplatin HIPEC was added to interval cytoreductive surgery in women with stage III ovarian cancer who had responded to chemotherapy. It is considered for selected patients and not for every woman.
How long is the operation and hospital stay?
The operation can take many hours, depending on how much disease needs to be removed. Most patients spend the first days in intensive or high-dependency care and stay in hospital for around one to two weeks, sometimes longer. Your team will explain what to expect for your case.
Will I still need chemotherapy?
Usually yes. Chemotherapy through a vein is commonly given before and/or after surgery, as advised by your medical oncologist. HIPEC works together with this treatment and does not replace it.
What is pseudomyxoma peritonei?
It is a rare condition, most often from a tumour of the appendix, in which mucus-forming cells spread inside the abdomen and produce jelly-like material. Cytoreductive surgery with HIPEC is the established treatment for suitable patients.
This page is for general information and is not a substitute for personal medical advice.