Evolving Role of CRS and HIPEC: Current Indications

Abstract

Peritoneal surface oncology is a dynamic field. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as an aggressive locoregional therapy that can prolong the life of selected patients with peritoneal metastases (PM). Initially, all sites of origin of PM were dealt with using the same prognostic variables, and the results were evaluated using the same parameters. Currently, PM secondary to various primary tumors or arising de novo from the peritoneum are dealt with individually with different indications, timing of CRS and HIPEC, and integration with other therapies. The indications may be considered fairly standardized. Though majority of these are supported by level 3 evidence that comprises of retrospective case series, these studies offer the most practical design for a situation where two radically different treatments (CRS and HIPEC versus systemic chemotherapy) need to be compared. Ongoing phase III trials in the therapeutic setting have been designed to compare CRS alone with CRS and HIPEC with or without other systemic therapies in various clinical scenarios. Like the role of surgery for nonmetastatic disease which has been established not by randomized controlled trials but through comparison with historical controls in most cancers, the role of CRS as a potentially curative treatment for selected patients with PM can be established based on the significant gain in survival over palliative therapies. It is the added benefit of HIPEC that is undefined in most conditions.