Overview of Cytoreductive Surgery With HIPEC
Cytoreductive surgery plus HIPEC is a comprehensive and specialized medical procedure designed to treat certain cancers within the abdominal cavity. Cytoreductive surgery (CRS) involves the meticulous removal of visible tumors and affected tissue, aiming to reduce the cancer burden to microscopic levels.
This is followed by hyperthermic intraperitoneal chemotherapy (HIPEC), a mesothelioma treatment where heated chemotherapy drugs are circulated within the abdominal cavity to eliminate residual cancer cells. The combination maximizes therapeutic impact by addressing both the visible and microscopic disease, offering improved outcomes for conditions like peritoneal mesothelioma while minimizing systemic toxicity.
Some patients receive a less aggressive and invasive cytoreduction/HIPEC for palliative purposes, which can extend survival by a few months and decrease discomfort from symptoms, such as abdominal fluid build-up (ascites) or tumors pressing against certain organs.
At the Medical College of Wisconsin, 17 cancer patients underwent 20 HIPEC surgeries for palliative reasons. While the average survival was less than one year, symptom management improved and reduced patient symptoms 90% of the time. Symptom relief was reduced or permanently resolved after HIPEC surgery for an average of 5.1 months.
Where Was Cytoreductive Surgery/HIPEC Developed?
Cytoreductive surgery with HIPEC is also referred to as CRS plus HIPEC or cytoreduction with HIPEC. It was developed at the end of the 20th century, thanks in large part to mesothelioma specialist Dr. Paul Sugarbaker of the Washington Cancer Institute. Dr. Sugarbaker’s influence on the development of this surgery is why it’s often called the “Sugarbaker Technique.”
Cytoreduction surgeries have existed since the middle of the 20th century. Dr. Joe Meigs at Massachusetts General Hospital in Boston first reported using tumor debulking surgery for the treatment of ovarian cancer in 1934. However, the procedure did not become widely used until the 1970s. Doctors began introducing intraoperative chemotherapy for abdominal cancer treatment in the 1970s and 1980s.
The development of cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal mesothelioma began in the 1990s. During this decade, Dr. Sugarbaker and colleagues introduced the Peritoneal Cancer Index (PCI) to stage new cases of malignant peritoneal mesothelioma and determine patient eligibility for safe surgery.
In 1995, Dr. Sugarbaker introduced the surgical procedure called peritonectomy to the cytoreduction portion. Peritonectomy is a precise technique to remove sections or the entire peritoneal (abdominal) lining to address cancers or diseases that involve the abdominal cavity.
Cytoreductive surgery is a highly specialized procedure aimed at manually removing visible tumors from the abdominal cavity, making it the only radical surgical option for patients with peritoneal mesothelioma. The primary goal of this “debulking” surgery is to eliminate all visible tumors and diseased tissue within the abdomen, although microscopic cancer cells may still remain.
During the mesothelioma surgery, surgeons often remove the omentum, which is a layer of fatty tissue covering the abdominal organs. Doctors also remove the entire peritoneum, which is the membrane lining the abdominal cavity.
Depending on the extent of the disease, other organs may need to be partially or completely removed if tumors are inseparable from the organ’s surface and removal poses no significant health risks. Organs that can be safely removed include the gallbladder, spleen, and sections of the small or large intestine, ensuring comprehensive tumor reduction while prioritizing patient safety.
An article published in JAMA stated surgeons may remove the pancreas, kidney, ureter, bladder and uterus without increasing severe complications or mortality rate.
HIPEC, or hyperthermic intraperitoneal chemotherapy, is a cutting-edge intraoperative treatment designed to target and kill peritoneal mesothelioma cancer cells.
Often referred to as “hot chemotherapy,” this technique has significantly improved outcomes for patients with this rare and aggressive disease. HIPEC involves delivering chemotherapy drugs directly into the abdominal cavity, reducing many of the side effects commonly seen with systemic (intravenous) chemotherapy.
During the procedure, doctors prepare a heated chemotherapy solution, often using drugs like cisplatin or carboplatin, with additional options including doxorubicin or mitomycin, depending on the case. The solution is heated to a precise temperature to enhance its cancer-fighting properties and circulated throughout the abdominal cavity for about 60-90 minutes.
Following the infusion, the chemotherapy drugs are drained, and the abdominal cavity is flushed with a sterile saline solution to remove any remaining chemotherapy agents. Despite its complexity, HIPEC is a vital component of treatment for patients with peritoneal mesothelioma, offering a targeted and effective approach to managing the disease.
What Is the Peritoneum?
The peritoneum is a layer of mesothelial tissue that lines the entire abdominal cavity and covers the abdominal organs. Composed of fluid and mesothelial cells, it serves as a protective barrier for the organs within the abdomen and aids in maintaining their proper function.
The peritoneum has two distinct tissue layers: the parietal peritoneum, which lines the walls of the abdomen and pelvis, and the visceral peritoneum, which wraps around the abdominal organs. Between these two layers lies the peritoneal cavity, a space filled with a lubricating fluid that reduces friction and allows the tissue linings to glide smoothly against each other. This fluid also allows the abdominal organs to move freely within the cavity, facilitating their proper function.
When tumors develop in either tissue layer of the peritoneum, this is called peritoneal mesothelioma. The tumors can disrupt the normal functioning of the abdominal cavity. As the tumor grows, they occupy space within the cavity, leading to symptoms such as abdominal pain, bloating, and loss of appetite.
