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CYTOREDUCTIVE SURGERY AND HIPEC IN OVARIAN CANCER

Ovarian malignancy is the most lethal of all gynecological cancers. Most common route of ovarian cancer spread is within the peritoneal cavity. Treatment options in ovarian cancer includes cytoreductive surgery (CRS) and chemotherapy. The standard of care for ovarian cancer is surgery in early stages and platinum-based chemotherapy followed by interval debulking surgery in advanced cases.

Cytoreductive surgery (CRS) is a complex operation in which all visible tumors within the abdomen will be remove. In addition to this, Heated chemotherapy solution is delivered immediately into the abdomen to kill the remaining tumor cells and this procedure is called as HIPEC, Hyperthermic intraperitoneal chemotherapy.

CRS-HIPEC to treat advanced cancers that are confined to the abdominal cavity and spread of the disease is mainly through peritoneal spread. It is most commonly used for ovarian cancer, appendix cancer, colorectal cancer, peritoneal cancers.

The main principal is heat which can directly kill cancer cells and improve the delivery and efficacy of chemotherapeutic drugs. A combination of heat and chemotherapy is an effective treatment for advanced cancers of the abdomen following optimal surgery.

The procedure is used only in certain circumstances. Determining factors include the patient’s overall health, the extent of the disease, how much of the tumour can be removed surgically, the primary site of the tumour, and the aggressiveness of the cancer. HIPEC can be considered in candidates undergoing optimal debulking surgery/ CRS, primarily or post primary chemotherapy treatment. Before starting HIPEC treatment, CRS should be performed, where as much of the tumour as possible from its primary location and surrounding areas are removed.

After the debulking/ CRS procedure, HIPEC treatment begins. During the treatment, two tubes will be inserted into the abdomen – one to deliver the heated chemotherapy solution and one to circulate the fluid out. The solution will be heated between 41 and 42 C and circulated in the abdomen for fixed period. After washing put the chemotherapy solution, the tubes and temperature probes are removed and abdomen is closed. Recovery from CRS-HIPEC treatment depends on the amount of cancer burden and extent of the operation. Surgery can last for hours, followed by a hospital stay of 10 to 14 days.

HIPEC is avoided in patients who are unable to tolerate cytoreductive surgery, in case of active abdominal infection, extensive intraabdominal adhesions, impaired renal or liver function which affects chemotherapy drug clearance. Bowel resection is not a absolute contraindication for HIPEC. Gross contamination by bowel contents should be avoided if planned for HIPEC.

HIPEC is associated with side effects. Most common side effect is excessive blood loss, resulting in transfusion among more than half of the patients. Other side effects include infections (eg, wound infection, sepsis, pneumonia, central line-associated infection, intra-abdominal infection), surgical wound dehiscence, bowel perforation, venous thromboembolism (blood clots in blood vessels), Renal failure/insufficiency and Liver failure. Patient should be evaluated and selected for the procedure of CRS with HIPEC.