HIPEC: HYPERTHERMIC
INTRAPERITONEAL CHEMOTHERAPY

The peritoneum is a thin membrane lining the abdominal cavity that cancer cells from nearby organs can seed and colonize. This process — peritoneal carcinomatosis — was once considered terminal; CRS-HIPEC has changed that.

• Peritoneal Cancer Index (PCI)

  The PCI scores disease extent across 13 abdominal regions (0–39). Scores ≤15–20 correlate with achievable complete cytoreduction and better survival. CT imaging often underestimates the true PCI.

• Completeness of Cytoreduction (CC Score)

  CC-0 (no visible tumor) and CC-1 (<2.5mm residual) are the only outcomes associated with survival benefit from HIPEC. Large residual disease negates the value of the procedure.

HIPEC delivers heated chemotherapy (41–43°C) directly into the open abdominal cavity immediately after cytoreductive surgery, exploiting both the peritoneal-plasma barrier and the thermal sensitization of cancer cells.

• The Peritoneal-Plasma Barrier

  Chemotherapy delivered intraperitoneally achieves 20–70× higher drug concentrations at peritoneal tumor deposits compared to intravenous delivery — with mitomycin C at 70× and cisplatin at 12× — while systemic absorption remains limited, keeping toxicity manageable.

• Why Hyperthermia Matters

  Heat above 41°C directly damages cancer cells (protein denaturation, membrane disruption), potentiates cisplatin and mitomycin C uptake, and blocks DNA repair of chemo-induced damage. The combination is synergistic — more effective than heat or chemotherapy alone.

• Open vs Closed Technique

  The "open" (Coliseum) method lifts the abdominal edges onto a drape for manual distribution. The "closed" method sutures the abdomen and circulates solution via pumps. Both achieve equivalent results; technique choice reflects center preference.

• 20–70×Higher chemo concentration vs IV delivery
• 41–43°COptimal perfusion temperature
• 6–12 hrsTypical total procedure duration
• 1–4%30/90-day mortality at high-volume centers

CRS-HIPEC has the strongest evidence and best outcomes in five peritoneal cancer types. The procedure is also applied in other cancers on a case-by-case basis at specialist centers.

• Pseudomyxoma Peritonei (PMP)

  Best outcomes of any indication — median OS exceeding 15 years for low-grade PMP. PMP does not respond to systemic chemotherapy; CRS-HIPEC is the only curative treatment. Early referral before disease becomes inoperable is critical.

• Peritoneal Mesothelioma

  Median OS 40–90 months with CRS-HIPEC vs 12 months with systemic chemotherapy. 5-year survival exceeds 40–50% at high-volume centers. Epithelioid histology is the strongest favorable prognostic factor.

• Ovarian Cancer (OVHIPEC Evidence)

  The OVHIPEC-1 Phase III trial (NEJM 2018, 245 patients) showed HIPEC added 12 months to median OS (45.7 vs 33.9 months) during interval cytoreductive surgery, with no increase in side effects.

• Colorectal Peritoneal Metastases

  The 2003 Verwaal trial nearly doubled median OS (22.4 vs 12.6 months) vs chemotherapy alone, with 45% 5-year survival after complete cytoreduction. PRODIGE 7 data questioned short oxaliplatin protocols; mitomycin C HIPEC remains widely used.

• Gastric Cancer (China Focus)

  Peritoneal metastasis occurs in 30–40% of advanced gastric cancer patients. CRS-HIPEC with cisplatin/MMC achieves median OS 18–36 months vs 8–12 months with chemotherapy. Chinese centers lead global experience for this indication.

Key survival outcomes from major trials and registry data for the five primary HIPEC indications.

Accurate patient selection is the single most important determinant of outcome. CRS-HIPEC is a major physiological undertaking — patients must have disease extent and fitness compatible with complete cytoreduction.

“Staging laparoscopy before committing to full CRS-HIPEC laparotomy avoids non-therapeutic major surgery in patients whose PCI was underestimated on CT.”

• Oncological Criteria

  Disease confined to the peritoneum (no systemic visceral metastases); PCI compatible with CC-0/1 cytoreduction; favorable histology (well-differentiated, non-signet-ring); no extensive small bowel root involvement. Adequate response to prior chemotherapy is favorable.

• Fitness Criteria

  ECOG PS 0–1 (selected PS 2 at experienced centers); adequate cardiopulmonary reserve; GFR ≥60 mL/min for cisplatin-based HIPEC; serum albumin indicating nutritional reserve. Age alone is not a contraindication — physiological fitness matters more.

The complete procedure takes 6–12 hours and is performed under general anesthesia by a specialist peritoneal surface oncology team.

1. 1

   Pre-Operative Evaluation

   CT/PET-CT staging, cardiopulmonary assessment, nutritional optimization, and staging laparoscopy to confirm PCI and resectability before full laparotomy.

2. 2

   Exploratory Laparotomy & PCI Scoring

   Full midline incision from sternum to pubis. The surgeon formally scores PCI, and the decision to proceed with cytoreduction is confirmed based on what is found.

3. 3

   Cytoreductive Surgery

   Systematic removal of all visible peritoneal tumor deposits via peritonectomy procedures, omentectomy, and organ resections as required. This phase takes 4–8 hours in extensive disease.

4. 4

   HIPEC Perfusion

   Heated chemotherapy (41–43°C) circulated through the abdomen for 60–90 minutes using open or closed technique. Agents: mitomycin C (colorectal/PMP), cisplatin ± doxorubicin (ovarian/mesothelioma).

5. 5

   Abdominal Lavage & Closure

   Chemo solution drained, peritoneal cavity lavaged with saline, bowel anastomoses completed, drains placed. Patient transferred to ICU for 1–3 days post-operatively.

Choice of agent is guided by tumor histology, pharmacokinetics, heat synergy, and center experience.

Cost varies significantly by country and extent of surgery. China and India offer specialist-level HIPEC at a fraction of Western costs.

Chinese surgical oncologists have made significant contributions to HIPEC literature — particularly for gastric cancer — and several Chinese centers perform HIPEC at volumes comparable to the world's best.

• Chinese PLA General Hospital (301 Hospital), Beijing

  One of China's highest-volume CRS-HIPEC centers with extensive gastric cancer and colorectal cancer peritoneal disease programs.

• Zhongshan Hospital, Fudan University, Shanghai

  Major hepatobiliary and peritoneal surgery center with an active HIPEC program for multiple tumor types.

• Cancer Hospital, Chinese Academy of Medical Sciences, Beijing

  National cancer center with a CRS-HIPEC program and multidisciplinary peritoneal oncology expertise.

• West China Hospital, Sichuan University, Chengdu

  Major surgical oncology center with a growing HIPEC program and active clinical research.

20 dedicated support pages provide deeper coverage of specific HIPEC topics.

Frequently Asked Questions About HIPEC