Hyperthermic Intraperitoneal Chemotherapy

The advanced-stage ovarian cancer management protocol used in our study is described in Fig. 1. All the patients, who were referred to one gynecologic oncologist for HIPEC, were thoroughly evaluated in order to determine the tumor burden of ovarian cancer. The diagnostic workup included esophagogastroduodenoscopy, colonoscopy, and CT of the chest, abdomen, and pelvis, with intravenous contrast agents. Positron-emission tomography CT was considered if extra-abdominal metastasis was suspected or difficult to detect by CT.
Our institution applied the following selection criteria for the use of NAC as the primary treatment strategy. NAC was performed when one of the following three criteria was met: 1) high tumor dissemination was observed on initial imaging studies and was assumed to occur under the following conditions: a) multiple and unresectable extra-abdominal metastases; b) multiple liver parenchymal metastases or pulmonary metastases; and c) extensive small bowel/mesenteric root involvement, 2) patients had a poor performance status and high operative risk because of medical comorbidities, or 3) optimal debulking surgery (residual disease measuring 1 cm or less) was unsuitable because of a high tumor burden (Fagotti score ≥8). For diagnostic laparoscopy, the degree of tumor burden was determined with the peritoneal carcinomatosis index (PCI) described by Harmon and Sugarbaker [7 (link)] and the Fagotti score [8 (link)].
All patients, preferably, were recommended to receive 3 cycles of NAC, IDS followed by HIPEC, and 3 cycles of postoperative adjuvant chemotherapy (POAC). HIPEC was not incorporated in patients in whom complete remission was achieved after 3 cycles of NAC. After NAC, complete remission was determined by a combination of the response to chemotherapy and radiologic findings and by the absence of operative findings of gross visible tumors. Additionally, HIPEC was not performed in patients with excessive bleeding (estimated blood loss ≥4,000 mL) during surgery and in cases of patient refusal. For NAC and POAC, all patients received carboplatin (area under the curve of 5 to 6) and paclitaxel (175 mg/m²).
At the time of IDS, the degree of tumor burden was also determined with Harmon and Sugarbaker's PCI and the Fagotti score. All patients underwent surgery with the intent to achieve complete cytoreduction (no gross residual disease). Every patient underwent the same routine of procedures, beginning with complete omentectomy, hysterectomy, bilateral salpingo-oophorectomy, and the removal of all macroscopically detectable lesions using surgical resection combined with electrofulguration, after peritonectomy techniques. If the rectosigmoid region was affected, it was resected ‘en bloc’ with digestive reconstruction by mechanical colorectal anastomosis. If the diaphragmatic region was affected, liver mobilization and diaphragmatic peritonectomy were performed. Pelvic and para-aortic lymphadenectomy was performed only for patients with gross nodal disease detected by preoperative imaging studies or operative findings.
HIPEC was performed immediately postoperatively. Of 27 HIPEC cases, 22 were performed using closed methods and 5 were performed using the open method. Paclitaxel was used at a dose of 175 mg/m², and chemotherapeutic agents were diluted in 3 L of 1.5% dextrose solution for peritoneal dialysis. Initially, 3 L of a heated perfusion solution was infused into the abdominal cavity at a rate of 800–1,000 mL/min through the inflow tube using the Belmont Hyperthermic Pump (Belmont Instrument Corporation, Billerica, MA, USA). Three intra-abdominal thermometers (1 positioned in the pelvis and 2 in the diaphragm area) were used to monitor the temperature inside the peritoneal cavity during the infusion, which remained constant between 42°C. The duration of the HIPEC procedure was 90 minutes, after which the perfusion solution was completely drained and bowel anastomosis was performed by the colorectal surgeon (MS Cho) if needed.