Current Status of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Colorectal Cancer (CRC).

Abstract

Accounting for 8.7% of global cancer deaths, colorectal cancer (CRC) is one of the leading causes of cancer-related mortality. Cytoreduction surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is part of a multimodal strategy for managing CRC. HIPEC is designed to target residual microscopic disease using heated chemotherapy. There are several techniques including the open abdomen "coliseum" technique, which uses a silastic sheet to create a perfusion chamber and allows for manipulation of contents; whereas the closed abdomen technique maintains a sterile environment and may involve abdominal wall massage for heat distribution; lastly, the laparoscopic method combines the benefits of both techniques with enhanced drug distribution through laparoscopy. Research has shown that the coliseum technique offers superior heat uniformity, while the laparoscopic method provides optimal distribution with advanced monitoring tools. We examined early trials, procedural variations, and recent clinical research to assess its efficacy. HIPEC involves the administration of heated chemotherapy directly into the peritoneal cavity after CRS in order to enhance local tumor control and survival. Various regimens that have been explored, including the Sugarbaker, triple dosing, and low dose mitomycin C regimen, report mixed results. The selection of chemotherapy drugs and their efficacy at high temperatures is crucial, with studies yielding mixed results for oxaliplatin and mitomycin C. The advantages of HIPEC, especially with oxaliplatin-based regimens, have been questioned by recent trials such as the PRODIGE 7 study because of problems like chemoresistance and greater postoperative morbidity. On the other hand, HIPEC is still supported by some as a good choice for individuals who are carefully chosen, particularly when combined with other forms of treatment. Despite being widely used in several cancer centers around the world for other pathologies, HIPEC remains a debated treatment option in CRC with peritoneal metastases. Even though the current evidence suggests that it might not provide a statistically meaningful overall survival improvement when compared to CRS alone, it might still be useful in some clinical settings or when combined with well-designed protocols. Thus, the necessity of more research and standardized protocols is paramount. Determining the role of HIPEC, maximizing patient selection, and contrasting its effectiveness with other intraperitoneal treatments such as pressurized intraperitoneal aerosol chemotherapy and early postoperative intraperitoneal chemotherapy will require ongoing trials and future research. Until clearer evidence emerges, HIPEC should be considered a therapeutic option for selected patients and offered by dedicated, experienced centers and surgical teams.