What information should be included in an informational document about Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at a hospital?

Essential Information for Hospital HIPEC Informational Document

What is HIPEC?

HIPEC (Hyperthermic Intraperitoneal Chemotherapy) is a specialized surgical procedure that combines complete tumor removal from the abdominal cavity with immediate delivery of heated chemotherapy directly into the peritoneal space during the same operation. 1 The procedure involves perfusing chemotherapy in a heated solution (41°C to 43°C) throughout the peritoneal cavity for 60-90 minutes, with the rationale that heat increases chemotherapy penetration at the peritoneal surface and enhances cancer cell sensitivity by inhibiting DNA repair. 1

Who Qualifies for HIPEC?

Primary Indication: Stage III Ovarian Cancer with Neoadjuvant Chemotherapy

HIPEC is recommended specifically for patients with stage III epithelial ovarian, fallopian tube, or primary peritoneal cancer who have received neoadjuvant chemotherapy (NACT) and are undergoing interval debulking surgery (IDS), NOT primary debulking surgery. 1, 2

Critical qualification criteria include:

• Stage III disease only (not stage IV with distant metastases) 2
• Completion of 3-6 cycles of neoadjuvant chemotherapy (3 cycles preferred) with documented response or stable disease 1, 2
• Planned interval debulking surgery (not primary surgery without prior chemotherapy) 1, 2
• Achievable complete or optimal cytoreduction (removal of all visible tumor) 2, 3
• Good performance status (able to tolerate extensive surgery and postoperative chemotherapy) 2
• Adequate renal function (as chemotherapy is nephrotoxic) 1

Exclusions - Who Should NOT Receive HIPEC:

• Patients with liver metastases, supraclavicular lymph node involvement, or extra-abdominal metastases 1, 2
• Patients with complete intestinal obstruction 1
• Patients undergoing primary debulking surgery without neoadjuvant chemotherapy (evidence shows no benefit) 1, 2
• Patients where complete cytoreduction cannot be achieved 2, 3

Procedure Details

Duration and Technique

• Total operative time: 5-10 hours (300-600 minutes including both cytoreductive surgery and HIPEC) 1
• HIPEC perfusion time: 60-90 minutes at intraperitoneal temperature of 41-43°C 1
• Standard chemotherapy agent: Cisplatin 100 mg/m² 2
• Both "open" and "closed" abdominal techniques are used, with closed technique showing better outcomes in some studies 1, 4

Hospital Stay

• Expected hospital stay: 8-24 days (median 10 days in recent trials) 1
• Extended stay compared to standard surgery due to procedure complexity 1

Risks and Complications

Mortality Risk

• Treatment-related mortality: 0.9-5.8% in contemporary series, with most recent trials reporting 0% procedure-related deaths 1, 3
• Historical studies reported up to 8% mortality 3

Major Complications (Grade 3-4)

Major complications occur in 9-40% of patients within 30 days, with the highest risk period extending to 60 days post-operatively. 1, 3

Common serious complications include: 1

• Infections: wound infections, sepsis, pneumonia, intra-abdominal infections, central line infections
• Gastrointestinal: fistulas, bowel perforation, ileus, surgical wound dehiscence
• Hematologic: excessive blood loss requiring transfusions (>50% of patients in some studies), anemia (67% of patients)
• Renal: kidney failure/insufficiency, creatinine elevation (15% of patients)
• Cardiovascular: venous thromboembolism, myocardial infarction
• Pulmonary: pleural effusions, pneumothorax
• Other: abscesses, hemorrhages, neutropenia, thrombocytopenia

Need for Additional Procedures

Many patients require additional surgical procedures to manage complications. 1

Expected Outcomes

Survival Benefits

In appropriately selected stage III ovarian cancer patients treated with NACT, HIPEC improves both recurrence-free survival and overall survival compared to surgery alone. 1 The M06OVH-OVHIPEC trial (n=245) demonstrated these benefits without increasing toxicity rates or negatively impacting quality of life. 1

Realistic Expectations

• Only 15% of patients with peritoneal metastases remain progression-free at 5 years, emphasizing the need for realistic expectations and close surveillance 3
• Completeness of cytoreduction is the most important prognostic factor - incomplete removal of visible tumor dramatically worsens outcomes 3

Required Postoperative Treatment

All patients must receive postoperative chemotherapy (typically 3 additional cycles of platinum-taxane doublet) after NACT and IDS with HIPEC, for a total of 6 cycles of chemotherapy. 1, 2

Center Requirements

HIPEC should ONLY be performed at specialized centers with:

• Substantial clinical experience in cytoreductive surgery and HIPEC 2, 3, 5
• Experienced gynecologic oncologists 1
• Strong critical care and intensive care support 5, 6
• Multidisciplinary team including medical oncology, surgical oncology, radiology, and pathology 3

Institutional experience directly correlates with decreased complication rates over time. 1, 7

Quality of Life Considerations

HIPEC does not negatively impact health-related quality of life metrics when compared to surgery alone, despite the longer procedure time. 1 However, patients should understand the extended recovery period, high complication risk, and need for intensive postoperative monitoring extending 60 days beyond surgery. 3

Decision-Making Process

HIPEC should be offered through a shared decision-making process that considers patient preferences, quality of life, and availability of specialized expertise. 1 Participation in HIPEC clinical trials is encouraged. 1