Cytoreductive Surgery with HIPEC

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care for peritoneal mesothelioma, showing promise in extending survival.

Key Points

  • 1

    Cytoreductive Surgery is a curative treatment aiming to remove all visible tumors.

  • 2

    This surgery is most often used with a heated chemotherapy wash, HIPEC, for best results.

  • 3

    This treatment is usually an option for earlier stage peritoneal mesothelioma patients.

  • 4

    Cytoreduction with HIPEC on average extends life expectancy to about 53 months.

Cytoreductive surgery, sometimes referred to as debulking, is a peritoneal mesothelioma treatment that aims to remove all visible tumors from the abdominal cavity. The surgery is often followed by hyperthermic intraperitoneal chemotherapy (HIPEC), a heated chemotherapy wash applied to the abdominal region to eliminate any remaining cancer cells.

HIPEC Surgery Success Rate

Mesothelioma specialists have seen improvements in peritoneal mesothelioma survival rate in recent years, largely thanks to this treatment combination. Across various studies, researchers have seen life expectancy improve on average to 53 months or more. The 5-year survival rate has improved to at least 50%, with several studies seeing even better results of 67% or higher.

One recent study found 100% overall survival in patients with complete tumor cytoreduction.

The remaining patients saw a median survival of nearly 98 months, with about 58 months disease-free.

Because of its high success rate, the multimodal therapy has become the standard of care for early stage peritoneal mesothelioma patients. Some studies have even found that surgery and HIPEC treatment may even achieve long-term survival in certain cases of more aggressive, advanced cancer. Typically, this multimodal treatment is only recommended for those with epithelioid mesothelioma, since that cell type responds well to treatment and doesn’t metastasize as aggressively as the other cell types. In a clinical trial, researchers found some patients with biphasic mesothelioma can still extend survival with this treatment. On average, biphasic mesothelioma patients achieved a 5-year survival rate of 50.2%, which is about equal to patients with the epithelial cell type.

Other clinical trials are also exploring updates to the treatment, such as minimally invasive surgical technique for patients diagnosed at an early stage. With further research, there’s hope surgery and HIPEC can continue to improve survival rates and maybe even lead to a cure.

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Cytoreductive Surgery Procedure

Cytoreductive surgery (CRS) is an extensive surgical procedure often recommended for patients with various abdominal and gastrointestinal cancers, like malignant peritoneal mesothelioma, ovarian cancer, appendiceal cancer, gastric cancer and colorectal cancer. The procedure is meant to remove any visible tumors in the abdominal region. The duration and extent of the procedure depends on the amount of visible tumors and their location, though doctors estimate the surgery followed by HIPEC to be about 8 – 14 hours on average.

Depending on the progression of the cancer, the surgery may entail the removal of nearby organs and tissues partially or completely.

Organs Commonly Affected in Cytoreductive Surgery
  • Peritoneum (lining of the abdominal wall)
  • Omentum (membrane connecting the stomach to other abdominal organs)
  • Spleen
  • Part of the liver
  • Part of the small or large intestine
  • Uterus or ovaries in female patients
  • Part of the gallbladder

Since the surgery is considered a more aggressive treatment, patients with advanced disease often are not candidates. If tumors have spread more distantly in the body or to lymph nodes, surgical removal becomes too difficult and risky. Initial CT scans and biopsies during diagnosis will help a mesothelioma doctor decide if a patient is eligible for this treatment.

How HIPEC Works

Once the doctor is confident that all visible tumors and diseased organs have been removed, the second step of the combination treatment can be applied. As implied by its name, HIPEC is a specific kind of chemotherapy solution that was developed specially for abdominal and peritoneal cancers. HIPEC is often described as a heated chemotherapy solution, as the treatment entails chemotherapy drugs (usually a combination of two) heated up to 104°F – 109°F. This temperature range is important, since research has shown cancer cells typically die at 104°F, but healthy cells will be destroyed at 111°F or higher.

The chemotherapy is applied directly to the peritoneal cavity through catheters and circulated throughout to destroy any remaining cancer cells. Since very little of the chemotherapy is absorbed, doctors can use higher doses than with systemic chemotherapy, while also avoiding some of the toxic side effects. The HIPEC procedure typically lasts for about 90 minutes.

Since HIPEC is a more specialized cancer treatment, it is only available at certain cancer centers across the country.

Recovery from CRS and HIPEC

Patients may have a hospital stay of a couple weeks, with up to two days in the ICU or Stepdown unit followed by eight to ten more days in the surgical unit. Surgical pain is controlled with a PCA (patient controlled analgesia) pump or IV pain medications. Some patients may also receive food and fluids through an IV until normal bowel and digestive function resumes. Recovery focuses heavily on digestive function, where most of the complications occur. With that in mind, nutrition will be a key part of a patient’s recovery, especially once discharged from the hospital.

While it’s important to rest after treatment, patients are usually encouraged to mobilize often by sitting in a chair or walking. Remaining active can also help combat some side effects, like fatigue and pneumonia. Patients might also routinely use an incentive spirometer to maintain proper lung ventilation and function throughout the recovery period.

Once discharged, normal activity generally resumes within four to six weeks with lifting restrictions. Patients should expect to have several postoperative appointments one to two weeks after being discharged to evaluate the patient’s status and continue working on an individualized care plan moving forward.

HIPEC Surgery Side Effects

Like any surgery, there are some potential risks and complications that may arise after treatment. It’s important for patients to pay attention to any side effects they may experience and tell their doctor right away. Many of the common complications from cytoreduction can be easily treated or even prevented with appropriate lifestyle changes during the recovery period.

Complications from Cytoreduction Surgery
Common Complications
  • Bleeding
  • Infection
  • Fatigue (may last 2 – 3 months)
  • Gastrointestinal problems, like abscess and gastric stasis (delayed emptying of the stomach)
  • Small bowel perforations
Rare Complications
  • Formation of blood clots in the legs that can travel to other parts of the body, like the lungs
  • Enterocutaneous fistula, an opening that can cause contents of the stomach or intestines to leak through the skin
  • Inability to consume calories

Some studies have also noted a high morbidity rate with this type of surgery. Patients considering this course of treatment should talk with their doctor about all of the potential risks and what they can expect following this treatment for their individual case.