Peritoneal Surface Malignancy and HIPEC
On this page
Direct answer
Heated chemotherapy lavage at 41-43°C delivered directly into the abdomen — hyperthermic intraperitoneal chemotherapy, HIPEC — is combined with cytoreductive surgery to treat disease spread on peritoneal surfaces, a territory systemic chemotherapy reaches poorly. Selection is everything: the peritoneal cancer index (PCI) sums lesion size across 13 abdominal regions to a maximum of 39, and only patients in whom all visible tumour can be removed (completeness of cytoreduction CC-0 or CC-1) benefit. The strongest indication is pseudomyxoma peritonei from appendiceal mucinous tumours; selected colorectal and ovarian peritoneal carcinomatosis and peritoneal mesothelioma follow. Mitomycin C or oxaliplatin circulates for 30-90 minutes at about 42°C while the surgeon agitates the abdomen. Morbidity of 30-50 per cent and mortality under about 5 per cent in experienced centres buy, for the right patient, long-term survival that palliative chemotherapy cannot.
What you must remember
- Rationale: peritoneal implants lie beyond effective systemic drug penetration and behind a plasma-peritoneal barrier; intraperitoneal delivery achieves high local concentration, and heat at 41-43°C both kills tumour directly and potentiates chemotherapy.
- PCI: 13 regions (nine abdomen-pelvis, four small bowel) scored 0-3 by largest lesion size; total 0-39 — the load meter that decides candidacy.
- Completeness of cytoreduction: CC-0 (no residual) and CC-1 (nodules under 2.5 mm) are the operable endpoints; CC-2/3 means palliation only.
- Best indications: pseudomyxoma peritonei/appendiceal mucinous neoplasm (the flagship, with long-term survival in a majority of complete resections), peritoneal mesothelioma, selected ovarian cancer, and colorectal carcinomatosis with low PCI.
- Colorectal cutoff: most centres decline disease above a PCI of about 16-20, and gross small-bowel or mesenteric surface disease is a common exclusion.
- Perirenal — the operation: peritonectomy procedures (Sugarbaker) strip involved parietal peritoneum plus organ resections as needed (greater omentectomy, splenectomy, rectosigmoid colectomy) to reach CC-0/1.
- Drugs and doses: mitomycin C (commonly about 30-40 mg over 60-90 minutes) or oxaliplatin-based regimens (about 30 minutes, often with glucose-based solutions); centre protocols vary.
- Complications: anastomotic leak, haemorrhage, ileus, renal injury, bone marrow suppression, deep vein thrombosis and hemodynamic stress during perfusion — hence the high-volume-centre rule.
How a candidate patient is worked
A 46-year-old woman presents with increasing abdominal girth and an ovarian mass; surgery reveals gelatinous ascites and peritoneal implants, and histology reports a low-grade appendiceal mucinous neoplasm — pseudomyxoma peritonei. Staging CT of chest and abdomen maps the peritoneal burden; diagnostic laparoscopy in selected cases scores the PCI before committing. If imaging and laparotomy confirm a PCI of, say, 14 with resectable distribution, the plan is complete cytoreduction: right hemicolectomy including the appendiceal primary, greater omentectomy, splenectomy and parietal peritonectomy of involved quadrants, with bowel anastomoses fashioned. Once CC-0 is achieved, the perfusion circuit runs: heated carrier fluid with mitomycin C at 42°C for 60-90 minutes, the surgeon's hands distributing heat and drug to every recess. She spends a week in hospital, morbidity-screened daily for leak, bleeding and neutropenia, and is discharged to surveillance CT and tumour markers.
The selection discipline shows best in the refused patient: a man with gastric cancer and linitis plastica, chylous ascites, small-bowel serosal scalloping and PCI above 20. Operation here means gross residual disease, a long recovery that consumes his remaining months, and morbidity without benefit — the honest answer is systemic therapy and palliation. Likewise in colorectal carcinomatosis, the data support HIPEC only for limited peritoneal spread amenable to complete cytoreduction, generally with low PCI, good performance status and absent extra-abdominal disease; treating it as a salvage after multiple failed chemotherapy lines yields poor outcomes and is the misuse that gave the technique its early critics.
Where the examiner frames it
Expect three question shapes: compute or interpret a PCI; state which malignancy is the best indication (appendiceal mucinous/pseudomyxoma); define CC-0 and why it matters. The viva trap is applying HIPEC to everybody with peritoneal disease — the candidate who answers with PCI thresholds, completeness and performance status demonstrates the selection thinking that is the actual examinable content. A second trap is mechanism: heat is not a gimmick — hyperthermia at 41-43°C is directly cytocidal, potentiates platinum and mitomycin uptake, and penetrates tumour nodules a few millimetres deep, which is why it is given only after macroscopic disease is removed. Indian context: dedicated peritoneal surface malignancy programmes exist in a handful of high-volume centres, so referral geography is a legitimate part of the answer.
Frequently asked questions
What is the peritoneal cancer index?
A score summing lesion size (0-3) across 13 abdominopelvic regions to a maximum of 39, quantifying disease load and determining eligibility for cytoreduction and HIPEC.
Which tumour is the flagship indication for HIPEC?
Pseudomyxoma peritonei from appendiceal mucinous neoplasms, where complete cytoreduction with HIPEC achieves long-term survival in a majority of selected patients.
What does completeness of cytoreduction CC-0 mean?
No macroscopic residual tumour after resection — the requirement for meaningful HIPEC benefit, alongside CC-1 (residual nodules under 2.5 mm).
At what temperature and for how long is HIPEC delivered?
Approximately 41-43°C for 30-90 minutes depending on the drug — mitomycin C commonly 60-90 minutes, oxaliplatin-based regimens about 30.
Why is HIPEC given only after complete cytoreduction?
Heat and drug penetrate only a few millimetres into tissue, so bulky residual disease is untreated — the technique complements, not replaces, surgical removal.