HIPEC (Hyperthermic Intraperitoneal Chemotherapy) & Cytoreductive Surgery (CRS)

Key points summarized from Dr. Healey Shulman's Grand Rounds presentation (Nov 1, 2024). Dr. Awad and Dr. Maclean have also provided very helpful practical pointers.

Indications

HIPEC is indicated for the treatment of certain peritoneal surface malignancies:

• Peritoneal carcinomatosis: secondary to cancers of the stomach, colorectal, ovary, and cervix.

• Pseudomyxoma peritonei

• Malignant peritoneal mesothelioma

• Sarcoma of the peritoneum.

• Adjunct for palliative managing uncontrolled malignant ascites.

Historically, peritoneal malignancies were considered incurable and only suitable for palliation. The goal of HIPEC combined with CRS is curative for certain peritoneal surface malignancies. CRS is to surgically remove all visible tumor mass, while HIPEC aims to eradicate any remaining microscopic disease.

The heated chemotherapy solution (usually between 40°C - 43°C) is intended to increase the penetration of the chemotherapy drugs into tumor tissue. Delivering chemotherapy directly to the peritoneal cavity allows for higher local concentrations of the drug, while limiting its systemic absorption / toxicity. Heat also enhances the cytotoxicity of the chemotherapy.

Nonetheless, CRS and HIPEC still represent a radical treatment modality with high perioperative morbidity and mortality. Appropriate patient selection is key to a successful outcome. Patients should have a good baseline health / functional status / nutritional status without significant cardiac or respiratory disease and ideally be under 70 years of age. The tumor should be confined to the abdominal cavity and the patient should have no disease progression on chemotherapy.

Surgical team also looks at tumor characteristics (load, organs involved, histopathology) during patients selection. 

At Sunnybrook, HIPEC is done in OR 5 for Gynecologic Oncology service.

Anesthetic Managements