What conditions is CRS/HIPEC used to treat?
CRS/HIPEC is used to treat advanced cancers that have spread throughout the abdominal cavity. These tumors can be caused by tumors of the appendix, colon, rectum, small bowel, ovary, fallopian tube, endometrium, stomach, and uterus, as well as from primary peritoneal cancers, sarcomas, mesothelioma, and other rare tumors. It is considered the standard of care for appendix cancer and peritoneal mesothelioma and is gaining support for use in newly diagnosed and recurrent gynecological malignancies. While often considered investigational, there is data supporting the use and potential benefit of CRS/HIPEC in a wide variety of tumor types (see list below).
​​Conditions that CRS/HIPEC may Treat
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Appendix Cancer
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Colon Cancer
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Endometrial Cancer
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Fallopian Tube Cancer
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Gastric Cancer
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Mesothelial Cysts
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Ovarian Cancer
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Peritoneal Mesothelioma
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Peritoneal Sarcomatosis
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Primary Peritoneal Cancer
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Pseudomyxoma Peritonei
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Small Bowel Cancers
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Uterine Sarcoma
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Other Select Cases of Rare Cancers (neuroendocrine tumors, pancreatic cancers, gallbladder cancer, prostate cancer, cervical cancer, breast cancer)
How are patients selected for CRS/HIPEC?
CRS/HIPEC is an extensive surgery requiring an experienced surgeon and strict selection criteria to obtain the best outcomes for patients. One of the most important selection criteria is evidence that your tumor can be completely removed based on imaging and/or with a diagnostic laparoscopy. Because CRS/HIPEC is considered a localized treatment that only targets abdominal disease, evidence of extraperitoneal disease, or disease outside of the abdomen, will exclude patients from being candidates for CRS/HIPEC. Other important selection criteria include:
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Age
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Performance status
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Prior surgeries or other therapies
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Extent of disease
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Quality of Life
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Physical and mental fitness
Who should get a CRS/HIPEC consult?
The short answer is anyone who has cancer that has spread in the abdominal cavity or has perforated an abdominal organ, such as a ruptured appendix tumor. CRS/HIPEC may be an option for newly diagnosed patients, as well as recurrent disease. It can also be used in sequence with other therapies, such as chemotherapy and radiation.
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Cancers with intraperitoneal metastases (that have spread to the abdominal cavity)
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Perforated abdominal cancers (ie. cancers that have penetrated through the original organ’s wall/capsule)
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Abdominal cancers with positive intraperitoneal cytology
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Peritoneal seeding of invasive cancer
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Large volume of peritoneal carcinomatosis or sarcomatosis
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No known extraperitoneal metastases (outside the abdominal cavity) (ie. bone or pulmonary)
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Advanced staged cancers
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Cancers with/without pleural effusions who respond to systemic chemotherapy
How do I locate CRS/HIPEC surgeons?
Many facilities across the United States and around the world are now performing the procedure, so there may be a high-quality care provider near you. To access a map of CRS/HIPEC surgeons to consider for your care, navigate to HIPECtreatment.com​​
Please Note: Our goal is to provide info to help you find a doctor closest to your home that can provide the best quality of care for your diagnosis or your anticipated CRS/HIPEC procedure. The Abdominal Cancers Alliance does not endorse any care provider or medical center over another.
How do I find a good CRS/HIPEC surgeon?
Surgical oncologists who specialize in peritoneal surface malignancies perform CRS/HIPEC. The complexity of the procedure requires an experienced surgeon to increase the likelihood of achieving a complete cytoreduction (removal of all visible tumor) and decreasing the chances for complications. One multi-center study concluded that CRS/HIPEC requires a steep curve of 140 procedures performed, which is significantly higher than more common surgical procedures to be considered an expert. In addition, The Chicago Consensus Guidelines require a minimum of 12 CRS/HIPEC procedures performed per year per surgeon to be considered a CRS/HIPEC center of excellence.
It is important to remember that CRS/HIPEC is an extensive surgery that requires not only an experienced surgeon, but also the combined expertise and knowledge of a multidisciplinary team, including physician assistants, skilled / critical care nursing, nurse navigators, physical therapists, dietitians, radiologists, pathologists, geneticists, and other cancer specialists to achieve the best outcomes.
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While many surgeons perform CRS/HIPEC, not all have the same level of expertise. Refer to the information below about finding a good CRS/HIPEC surgeon and refer to our list of questions to ask a surgeon so that you can vet your care team with confidence.
What tests will determine if I am a candidate?
Important tools to determine CRS/HIPEC eligibility include a physical exam, radiographic imaging (CT, MRI or PETCT) of the chest, abdomen, and pelvis, serum tumor markers (CA-125, CEA, and CA 19-9), and other general bloodwork. Since peritoneal disease is difficult to assess on radiographic imaging, your surgeon may recommend a diagnostic laparoscopy prior to CRS/HIPEC to better assess the probability of resection without an extensive surgical procedure. In addition, a colonoscopy may be required to see if any tumor has penetrated through the bowel and help build a surgery plan.
CRS/HIPEC Work Up
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Physical Exam
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Basic Blood Work (CBC, Metabolic panel, Creatinine clearance)
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Tumor and Inflammatory Markers (CEA, CA 19-9, CA 125, CRP)
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Imaging (CT or MRI) of the chest, abdomen, and pelvis
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Colonoscopy
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Diagnostic Laparoscopy (when indicated)
How do I prepare for CRS/HIPEC?
Recovery from CRS/HIPEC can take a long time. The hospital stay is usually 12 to 15 days; however, it takes up to 2 months for most patients to return to regular activity. Many patients do not feel “back to normal” until 6 to 12 months after the procedure. Therefore, it is important to try to be as healthy as possible before going into surgery. Eating a well-balanced diet, maintaining weight, and building strength and stamina will help you recover faster.
In addition to getting physically prepared for HIPEC, it is also important to be mentally prepared. Recovery is a marathon, not a sprint and maintaining resilience and a strong support system will be essential. A dedicated support team of family and/or friends to help you throughout your recovery will be crucial for success. No one can do it alone.
What procedures will be done during my surgery?
This is often a difficult question for surgeons to answer since they often don’t know the true extent or exact location of the disease until they look in the abdomen during surgery. The amount and distribution of disease that you have is measured using the Peritoneal Cancer Index (PCI), which ranges from 0 (no tumor) to 39 (extensive disease). In general, peritonectomies, or the removal of the lining of the abdominal cavity, will be performed. In addition, organs, such as the gallbladder, spleen, uterus, and ovaries, may be required. Many patients also require a bowel/colon resection. Your surgeon makes intraoperative decisions on what to remove based on the probability of achieving a complete cytoreduction and maintaining quality of life. The most important aspect to achieving extended survival and even cure is directly related to the surgeon being able to remove all visible tumor.
Will I need an ostomy?
A colostomy or ileostomy is a surgical procedure where a piece of the bowel is diverted through an artificial opening in the abdominal wall. Instead of having bowel movements through the rectum, stool will be collected in a bag attached to a piece of diverted bowel on the abdomen. In the literature, the rate of ostomy formation ranges from 0-25% of HIPEC procedures. However, it depends on the location of tumor and extent of bowel involvement, especially when the whole colon is involved. Ostomies can be temporary or permanent. Temporary ostomies are used when reconnecting the bowel at the time of surgery is at high risk for leaking due to stress from surgery. Once you have healed, your surgeon will bring you back for another operation to close the ostomy and reconnect the bowel. This smaller procedure is usually performed 3 to 6 months after the CRS/HIPEC.
Permanent ostomies are performed for several reasons. First, they can be performed in a palliative setting for symptom control to bypass a part of the bowel that is obstructed by tumor. Second, it can be performed if there is tumor that is deep in the pelvis involving the rectum. Finally, an ostomy may be required because the amount of bowel that had to be removed to get rid of all the tumor made the remaining bowel too short to be reconnected or the amount of remaining colon is not enough to absorb enough water from the stool to prevent diarrhea and too frequent bowel movements (known as short gut syndrome). In this instance, it may be better for the patient to manage an ostomy instead of having to go to the bathroom multiple times per day.
Requiring colostomy or ileostomy is often one of the biggest concerns of patients as it requires a significant change to everyday life. However, the technology behind ostomies has greatly improved and you would never know that many people have one. They even make special bathing suits to accommodate ostomies. The decision to perform an ostomy can be discussed with your surgeon before surgery and can help your doctor when having to make choices in the operating room. In many centers, a specialized nurse will meet with you ahead of surgery to mark the best locations on your abdomen for an ostomy to avoid folds in your skin or where the waist of your pants normally hit. If you end up needing an ostomy, this nurse will meet with you again postoperatively to teach you how to care for and use it in your everyday life.