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Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
With cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), advanced abdominal cancers can now be treated with higher efficacy, fewer chemotherapy-related side effects, less complications and better survival than conventional chemotherapy. Immediately following surgical resection of all visible tumours and/or surface cancer spread within the abdomen, HIPEC completes the extensive annihilation of any residual cancer cells by direct delivery of heated, sterilised chemotherapeutic drugs into the abdomen of suitable patients.

About Peritoneal Cancer
The peritoneum is the membrane that lines the abdominal cavity and internal organs. Peritoneal surface malignancies, commonly known as peritoneal cancers, refer to a variety of tumours that extensively involve the peritoneal lining of the abdominal wall, as well as the peritoneal surface of the internal organs, such as the liver, colon, stomach and omentum. These tumours can arise from the peritoneum but more commonly, originate from the malignancy of the appendix, rectum, colon, stomach, ovaries and other organs. The spread to the peritoneum and other internal organs usually signifies advanced stage cancer.

Incidence and Severity of the Disease
Primary cancers from the peritoneum are not common and these include primary peritoneal cancer, the characteristics of which are similar to ovarian cancer; and peritoneal mesothelioma, which is a rare tumour related to exposure to asbestos.

Peritoneal metastases are not uncommon in case of primary gastrointestinal cancer and ovarian cancer. In colorectal cancer, 5-10% of patients have peritoneal metastasis on presentation and about 25% will develop peritoneal metastasis subsequently. About one-third of patients have isolated peritoneal metastasis. All of the epithelial ovarian cancer beyond FIGO (International Federation of Gynaecology and Obstetrics) stage IIB will develop peritoneal carcinomatosis as a natural course of disease progression.

Spread of the tumour to the peritoneum also occurs in other cancers of the gastrointestinal tract. In case of mucinous tumours of the appendix or ovary, widespread peritoneal involvement with mucinous materials will give rise to the condition known as pseudomyxoma peritonei.

Conventional Treatment
Except for a few cancers such as ovarian cancer, conventional chemotherapy does not have significant effect on peritoneal malignancies. Without treatment, the patients will have survival of less than 6 months. New novel targeted therapy and immunotherapy can help improve the outcome, but long-term survival is uncommon.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
One of the current treatments for advanced stage abdominal cancer is cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

Cytoreductive surgery is a procedure performed to remove all visible tumours within the abdomen. This involves resection of the peritoneal metastasis together with resection of involved organs and multi-visceral resection may be needed. HIPEC is a heated, sterilised chemotherapy solution which is delivered directly to the abdomen immediately following cytoreductive surgery. The goal is to penetrate and destroy cancer cells that remain in the abdomen after surgery.

Cytoreductive surgery in combination with HIPEC is a treatment option for people who have advanced surface spread of cancer within the abdomen, without disease involvement outside of the abdomen. It may be used to treat some cases of:

There are potential benefits of HIPEC. In comparison to traditional chemotherapy delivery, HIPEC allows for higher doses of chemotherapy treatment. Heating the solution (i.e., hyperthermia) also enhances the power of the chemotherapy, improving absorption by tumours and susceptibility of tumour cells to chemotherapy. And, because the chemotherapy is kept within the abdomen, it minimises the rest of the body’s exposure to the treatment and helps reduce the side effects of chemotherapy.

Current Status and Indications
Cytoreductive surgery and HIPEC are currently indicated for peritoneal cancer originating from abdominopelvic tumours such as colorectal cancer, appendiceal cancer, ovarian cancer, primary peritoneal cancer and peritoneal mesothelioma, if the primary tumour could be radically resected or optimal cytoreduction could be achieved and there are no widespread systemic metastases.

Cytoreductive surgery and HIPEC is the treatment of choice for peritoneal mesothelioma and pseudomyxoma peritonei from appendiceal and ovarian origins. Current literature also suggests that cytoreductive surgery and HIPEC offer better outcome than chemotherapy in patients with peritoneal metastasis from colorectal and ovarian primaries.

For other cancers such as stomach cancer and pancreatic cancer, it can be assessed on an individual basis.

Targeted Patients

Many of these patients have undergone previous surgery and medical treatment. Careful selection, assessment and perioperative management are important to achieve good outcome and avoid unnecessary operations and complications. Good outcome and prognosis depend on the extent of peritoneal metastasis and the completeness of cytoreduction. The operation should be performed by doctors of appropriate specialties, especially when multi-visceral resection is carried out. Careful patient selection, intraoperative decision and postoperative management are important to avoid complications.

Perioperative chemotherapy/targeted/immunotherapy should be offered appropriately by the clinical/medical oncologist to patients.