When a patient has peritoneal metastatic disease and fewer treatment options remain, an early evaluation by a peritoneal malignancy surgical oncologist can help determine whether the patient may benefit from cytoreduction surgery, with or without HIPEC, and guide next therapeutic steps before the disease advances further.

Stephanie H. Greco, MD, FACS, a highly experienced specialist in peritoneal surface malignancies and Associate Professor in the Fox Chase Cancer Center Department of Surgical Oncology, regularly consults with patients who have peritoneal metastatic disease to determine whether surgery should be part of the treatment plan. “Not every patient will meet the criteria for surgery, but a timely referral can give patients, medical oncologists, and other referring physicians a clearer view of all available options,” said Greco.

During cytoreduction surgery, the surgeon removes visible peritoneal tumors, and then, the abdominal cavity is bathed with a heated chemotherapy solution for up to 90 minutes in the OR to help destroy remaining microscopic cancer cells and reduce the risk of recurrence.

For many patients with advanced appendiceal cancers, cytoreduction with HIPEC is considered standard of care. For appropriately selected colorectal, ovarian, and gastric cancers, it may extend survival, increase time off systemic therapy, improve disease control, or help relieve symptoms.

In colon cancer, the addition of HIPEC to cytoreduction became controversial after a European trial found no overall survival difference from adding HIPEC, though Greco points to important nuances: the chemotherapy used in Europe was different from what is used in the U.S., and subset analyses did suggest a possible benefit.

Greco also explains that “unlike some therapies that cannot be repeated, for selected patients, cytoreduction and/or HIPEC can be performed more than once.”

In many cases, an early evaluation for cytoreduction surgery—with or without HIPEC—expands the possible range of treatment options for appropriate patients.

 

Managing Peritoneal Metastatic Malignancies:

Cytoreduction Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
For certain patients with peritoneal metastatic malignancies of the appendix, ovaries, colorectal and gastric systems, and some sarcomas, cytoreduction surgery with HIPEC is a viable treatment option. Below are case studies that demonstrate its clinical value.

DIAGNOSIS: LIMITED STAGE IV GASTRIC CANCER

Patient Profile
A patient in their late 40s presented with abdominal pain, significant weight loss, and vomiting. Gastric cancer was confirmed, and additional staging showed cancer cells in peritoneal washings, classifying the disease as stage IV.

Clinical Course
The metastatic disease appeared limited, so the care team considered a two-pronged approach. First, the patient completed systemic chemotherapy and then underwent cytoreduction surgery with HIPEC and subtotal gastrectomy. At the time of surgery, there was no obvious visible metastatic disease; the patient recovered well and is currently being followed on surveillance with no evidence of disease. Ongoing management includes maintenance therapy.

Dr. Greco notes: Since the patient was younger and the disease more limited, we recommended an up-front, aggressive approach.

DIAGNOSIS: APPENDIX CANCER WITH PSEUDOMYXOMA PERTONEI

Patient Profile
A patient in their 70s presented with pseudomyxoma peritonei, commonly associated with appendix cancer. Biopsy of an omental mass showed a low-grade appendiceal mucinous neoplasm, characterized as an appendix cancer.

Clinical Course
Dr. Greco recommended surgery rather than neoadjuvant chemotherapy because the patient needed extensive debulking, including removal of the omentum and part of the pancreas, spleen, colon, peritoneal surfaces, and gallbladder, as well as other visible sources of disease—along with HIPEC. Final pathology was upgraded to mucinous adenocarcinoma, which did not change the management plan. The patient went onto surveillance and has had no evidence of disease from the appendix cancer.

Dr. Greco notes: If/when a woman presents with pseudomyxoma, ovarian cancer is often mistakenly suspected; suspected pseudomyxoma should prompt referral to a surgical oncologist who specializes in HIPEC.