Cytoreductive Surgery and HIPEC

How to Get Cytoreductive Surgery With HIPEC for Your Mesothelioma

To learn more about cytoreductive surgery with HIPEC for your peritoneal mesothelioma, our patient advocates are available to help. They can guide you through the necessary steps to find highly-rated medical care and top mesothelioma specialists:

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

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

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.

Multimodal Therapies With Cytoreductive Surgery and HIPEC

Systemic (intravenous) chemotherapy (typically pemetrexed and either cisplatin or carboplatin) for peritoneal mesothelioma is the primary treatment option. Systemic chemotherapy is often a combined treatment with cytoreductive surgery and HIPEC. Doctors can use mesothelioma chemotherapy either before or after cytoreductive surgery.

Doctors may use an alternative type of intraperitoneal chemotherapy treatment for malignant peritoneal mesothelioma. Dwell chemotherapy is a method of delivering chemotherapy drugs directly into a specific area of the body, often through a catheter or other delivery system, to treat localized cancers.

This local delivery increases drug concentration at the tumor site while reducing systemic toxicity. Doctors can then deliver chemotherapy drugs into the abdominal cavity multiple times in the weeks following surgery. While this method produces higher local drug concentration and lower systemic side effects, the placement of a catheter or port carries risk of infection and/or complications.

An alternative to chemotherapy is immunotherapy. Drugs such as nivolumab (Opdivo) and ipilimumab (Yervoy) are checkpoint inhibitors used to target pathways that boost our immune response.

Doctors are becoming more supportive of this treatment option for peritoneal mesothelioma cases. Immunotherapy for patients with diffuse malignant peritoneal mesothelioma is available through clinical trials.

What Happens During a Cytoreductive Surgery/HIPEC?

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is a long, complex surgery. Prior to incision, the patient is given anesthesia and closely monitored throughout the surgical procedures. The patient is properly positioned for surgery to ensure a safe surgical experience.

CRS and HIPEC for malignant peritoneal mesothelioma can take up to 14 hours. The extent of the cancer determines how long the surgery takes.

8 Steps of Cytoreductive Surgery and HIPEC

Here are the steps of cytoreductive surgery with HIPEC:

If the patient is scheduled to receive dwell chemotherapy as an adjuvant (post-surgical) treatment, doctors will leave the catheters in the abdomen at the end of the surgery. These catheters will provide direct access into the abdominal cavity and offer a path to administer additional chemotherapy treatments to that area.

Closed-Abdominal HIPEC Versus Open-Abdominal HIPEC

There are two main techniques for HIPEC:

• Closed-abdominal HIPEC prevents heat from escaping the abdominal cavity and increases the effectiveness of the drugs. It also prevents drug spillage or leakage from the abdominal cavity since the incision is closed. This aids in drug penetration into the tumors.
• Open-abdominal HIPEC offers good chemotherapy drug distribution. This washes the abdominal cavity with the liquid and reaches hidden crevices. However, drug leakage and heat loss are concerns.

The choice between closed-abdominal HIPEC and open-abdominal HIPEC depends on several factors:

• Surgeon preference and experience: Some surgeons favor direct visualization for better control, while others prioritize safety and simplicity.
• Patient factors: Anatomical complexity, presence of adhesions, and disease distribution may influence the decision.
• Institutional resources: Availability of specialized equipment and protocols for staff protection and experience play a role.
• Chemotherapy agent: Certain agents may require specific delivery methods for optimal efficacy.

Both methods are effective, and outcomes largely depend on achieving complete cytoreduction and ensuring uniform exposure of peritoneal surfaces to the heated chemotherapy.

Recovery Time After Cytoreductive Surgery With HIPEC

According to the surgeons at Johns Hopkins Medicine in Baltimore, MD, complete cytoreductive surgery with HIPEC requires approximately 2-3 months of recovery. Patients should expect to spend 10-14 days in the hospital following surgery. Additional recovery continues for 6-10 weeks after discharge from the hospital.

Inpatient Recovery

Following surgery, most patients go to the intensive care unit (ICU). They will be monitored carefully and receive IV fluids and pain medication to help with recovery. Patients may experience bowel issues due to the length of the surgery.

The postoperative team will monitor bowel function, fluid and food intake, as well as progress with mobility (getting up to a chair and walking). This helps determine when a patient can transition from inpatient recovery to outpatient recovery.

Outpatient Recovery

Outpatient recovery can happen either at the patient’s home, the home of a loved one, or a medical rehabilitation facility. The outpatient recovery time varies.

Patients may remain on IV fluid treatments to ensure they receive nutrition. This also helps the digestive system recover.

Patients who undergo CRS and HIPEC will have regular follow-up appointments with the surgical specialist and oncologist. These check-ins are to monitor imaging scans for success of the surgery signs of recurrence. The patient will often have their first follow-up within a couple of weeks after hospital discharge. They will continue every few months initially, then transition to every six months and eventually advance to annual check-ins.

Who Can Get Cytoreduction/HIPEC for Peritoneal Mesothelioma?

Patient eligibility for cytoreduction followed by hyperthermic intraperitoneal chemotherapy depends on a few factors. The first is the PCI score, as this score summarizes the extent of the tumors present in the abdomen, how far the tumors have spread and if the tumors have infiltrated to the abdominal organs.

Other factors affecting who can have this surgery are:

• Physical health
• Age
• Cell type

Cytoreduction With HIPEC Eligibility: PCI Score

A patient’s PCI score is a significant factor in determining if a patient is a candidate for cytoreductive surgery. PCI is a numerical scoring system used to quantify the tumor burden in the peritoneal cavity. This score is an important measuring tool used to evaluate how far the tumors have spread in the abdominal cavity. If the cancer is too advanced, surgery won’t remove enough of the disease to improve the patient’s life expectancy.

Peritoneal mesothelioma specialists have different opinions on what PCI score is too high to operate. Dr. Shanel Bhagwandin, from Jupiter Medical Center, said scores higher than 20 often don’t qualify for surgery.

Cytoreduction With HIPEC Eligibility: Physical Health

Physical health is an important factor in eligibility for invasive surgery. Since cytoreduction with HIPEC involves an open abdominal surgery, removal of tissue and organs, and the use of heated chemotherapy, patients must be strong enough to withstand anesthesia, postoperative recovery and postoperative pain.

If the patient has a concerning medical history or lingering health issues, surgeons may avoid aggressive treatment. Operating on patients in poor health can cause severe complications.

Cytoreduction With HIPEC Eligibility: Age

Cytoreductive surgery and perioperative intraperitoneal chemotherapy is an aggressive treatment for peritoneal mesothelioma. This procedure would be difficult for most patients but especially challenging for older patients. Younger patients with this rare cancer are more likely to be in better overall health and able to tolerate the procedure and recover from this surgery.

Alexis Kidd, a peritoneal mesothelioma survivor of more than 13 years, received cytoreductive surgery with HIPEC in her late thirties. The average age for peritoneal mesothelioma patients is between 50 and 60.

Older patients — those in their sixties, seventies or eighties — may still qualify for the HIPEC procedure, but the selection process would need to determine if cytoreduction plus HIPEC was possible. It is important to discuss all treatment options with a mesothelioma specialist.

Cytoreduction With HIPEC Eligibility: Cell Type

Mesothelioma cell type is another important aspect in determining eligibility for surgery. Epithelioid mesothelioma cells are easier to treat, due to being the easiest to identify and remove. Sarcomatoid cells grow and spread faster than other cell types, which makes it more difficult to identify and treat.

Some surgeons may choose to be more aggressive and only accept patients with the epithelioid cell type. Sarcomatoid and biphasic mesothelioma types are still considered for surgery but present a more challenging surgical candidate. Specialists may choose other treatment alternatives in the management of their disease.

Survival After Cytoreductive Surgery

Fortunately, there has been a steep improvement in the life expectancy for people with peritoneal mesothelioma, which is attributed to the development and advancement of cytoreductive surgery and HIPEC treatment.

The National Cancer Database includes 700 cases of peritoneal mesothelioma treated with cytoreduction and HIPEC. The average survival was 38 months (3 years, 2 months). If patients did not receive surgery, their survival was 7.1 months on average.

Wake Forest Baptist Cancer Center reported a median survival of 40 months (3 years, 4 months). The five-year survival rate was around 30%. Other centers report five-year survival rates of around 50%.

Importance of Getting HIPEC Surgery Soon After Diagnosis

Medical experts suggest cancer patients begin treatment right after diagnosis. The longer patients wait, the more likely the cancer will spread and become untreatable with surgery or immunotherapy.

Many studies support this theory, showing how patients getting treatment immediately will improve their survival and life expectancy. For peritoneal mesothelioma patients, the main option is HIPEC surgery and there’s scientific data supporting surgery as soon as possible.

The Journal of Gastrointestinal Surgery published a report comparing the wait times for peritoneal mesothelioma patients — and the effect on survival. When patients get HIPEC/cytoreductive surgery within four weeks of their diagnosis, their life expectancy is more than 5 years.

The longer the wait time for surgery, the worse the life expectancy:

• Delayed surgery (4-12 weeks after diagnosis) — 4.8 years of life expectancy
• Delayed surgery (13-24 weeks after diagnosis) — 4.37 years of life expectancy
• No surgery — 2.1 years of life expectancy

Survival After Surgery and Multimodal Treatment

Adding systemic chemotherapy after cytoreduction and HIPEC can improve the life expectancy for malignant mesothelioma of the peritoneum. This is a common multimodal treatment used with the HIPEC procedure.

Giving chemotherapy for diffuse malignant peritoneal mesothelioma before surgery is called “adjuvant chemotherapy.” The National Cancer Database research showed a median survival of 41.2 months (3 years, 5 months) when chemotherapy was used after surgery. Another is immunotherapy through clinical trials, this treatment is currently the only FDA-approved treatment for pleural mesothelioma.

Dwell chemotherapy is another intraperitoneal chemotherapy for malignant peritoneal mesothelioma. The ports used with HIPEC during surgery are left in the abdomen when surgery ends. This allows doctors to deliver liquid chemotherapy directly into the abdominal cavity multiple times in the weeks following surgery. For peritoneal mesothelioma, the dwell chemotherapy used is “NIPEC” (normothermic intraperitoneal chemotherapy).

Alexis Kidd received NIPEC following her cytoreductive surgery with HIPEC. She’s one of the longest survivors of peritoneal mesothelioma, largely thanks to cytoreductive surgery with HIPEC and NIPEC.

Possible Complications From Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma

Patients may experience complications from cytoreductive surgery and HIPEC. Many are related to the digestive tract:

• Gastrointestinal problems (bowel blockage, nausea and vomiting)
• Small perforations of the bowel (a hole in the stomach, small intestines or colon)
• Intraperitoneal abscesses (infection with collections of pus in the abdominal cavity)
• Pancreatic fistulas (leakage of pancreatic fluid into the abdominal cavity)
• Gastroparesis (paralysis of the stomach – food not being pushed down into small intestines)
• Pleural effusions (fluid surrounding the lungs)
• Pneumonia
• Infections

Risk factors for complications during or after cytoreduction/HIPEC surgery include:

• High PCI score: A high PCI score indicates an extensive tumor burden and more complex surgery.
• Patient comorbidities: Patients who suffer with conditions like diabetes, cardiovascular disease, or malnutrition are at an increased risk of complications following surgery.
• Advanced age: Patients above 60 years old are more prone to postoperative complications.
• Prolonged surgical procedure: This increases the risk of infections, blood loss, and possible organ dysfunction.

Mesothelioma Recurrence After Cytoreduction With HIPEC

A report in the Journal of Gastrointestinal Oncology assessed that most mesothelioma patients will have recurrence after HIPEC surgery. It occurs within the abdominal cavity in up to 57% of patients.

Recurrence can occur locally within the peritoneal cavity or systemically, depending on factors such as the initial tumor burden (PCI score), completeness of cytoreduction, and tumor biology. Patients with recurrent disease may be considered for additional treatments, including repeat CRS with HIPEC, systemic chemotherapy, or palliative care, depending on their overall health and the extent of the recurrence.

Regular monitoring with imaging and tumor markers is essential to detect and manage recurrence early. A second surgery can improve the already elevated survival times for this operation:

• A 2014 study of 65 patients reported a median survival of nearly 4 years
• In 2015 a study of 44 patients, reported a median survival of 4.5 years.

Mortality Assessment of Cytoreductive Surgery With HIPEC

Researchers from the University of Nebraska-Omaha Cancer Center reported a 30-day mortality rate of 1.1% for cytoreduction with HIPEC. This was much lower than the mortality rates for these other major surgeries:

• Tri-segmental hepatectomy (surgery that removes all or part of the liver)
• Right lobe hepatectomy (surgery that removes one lobe of the liver)
• Pancreaticoduodenectomy, also known as a Whipple procedure (surgery that removes cancer of the head of the pancreas – removing the head of the pancreas, the first part of the small intestine, the gallbladder and the bile duct)
• Esophagectomy (surgery to remove all or part of the esophagus)

Quality of Life After Cytoreduction With HIPEC

Quality of life is a significant concern for patients considering peritoneal mesothelioma surgery. Increased discomfort and additional health concerns are always possible following any major operation.

Researchers at Wake Forest Baptist Cancer Center reported improvement in quality of life following the HIPEC procedure. Their physical functioning initially worsened but then reached preoperative normalcy at the one-year mark.

Other findings were:

• General health improved by the six-month mark after surgery
• Emotional well-being and social functioning improved after surgery
• Physical pain decreased after surgery

The researchers wrote that patients “may tolerate HIPEC well and have good overall quality of life postoperatively.” Alexis Kidd herself vouches for cytoreduction with HIPEC for her own quality of life.

Specialists Who Perform Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma

There is a long list of doctors who perform cytoreductive surgery followed by HIPEC. There are surgeons in each region of the country who specialize in peritoneal mesothelioma. They work at the top cancer centers in the world, with vast resources at their disposal.

Some of the top mesothelioma surgeons who perform cytoreductive surgery and HIPEC:

• Dr. James Pingpank, UPMC Hillman Cancer Center (Pittsburgh, PA)
• Dr. Eugene Choi, Baylor St. Luke’s Health Medical & Houston VA Medical Center (Houston, TX)
• Dr. Edward Levine, Wake Forest Baptist Cancer Center (Winston-Salem, NC)
• Dr. Richard Alexander, Rutgers Cancer Institute (New Brunswick, NJ)
• Dr. Joel Baumgartner, University of California-San Diego Moores Cancer Center (San Diego, CA)
• Dr. Mecker Moller, University of Miami Sylvester Comprehensive Cancer Center (Miami, FL)
• Dr. Kamran Idrees, Vanderbilt University-Ingram Cancer Center (Nashville, TN)

Finding Surgical Treatment in the VA Health Care System

The VA healthcare system provides veterans access to the top cancer doctors in the world. Three VA hospitals have mesothelioma treatment programs, staffed by experienced surgeons and oncologists from nearby cancer centers.

The Houston VA program is the only one known to treat peritoneal mesothelioma. Dr. Eugene Choi is the head peritoneal mesothelioma surgeon at the Houston VA Medical Center.

If you need help with your VA benefits and finding a VA hospital, please reach out to LCDR Carl Jewett. As a VA-accredited claims agent and patient advocate, he can help you find the specialized treatment strategies you need.