HIPEC: The Gold Standard for Peritoneal Mesothelioma
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) represents the most effective treatment for peritoneal mesothelioma. Long-term data from high-volume centers now shows that a significant portion of patients can be considered cured.
28-year outcome data:
- 43.6% cure rate for patients surviving 7+ years
- Median survival: 53-103 months depending on tumor factors
- 5-year survival: 47-52% at specialized centers
What Is CRS/HIPEC?
The Procedure
CRS/HIPEC is a two-part surgical treatment:
1. Cytoreductive Surgery (CRS)
- Removal of all visible tumors from the abdominal cavity
- May include removal of affected peritoneum, organs, or organ portions
- Goal: Complete cytoreduction (CC-0 = no visible disease remaining)
2. Heated Intraperitoneal Chemotherapy (HIPEC)
- Immediately follows surgery while abdomen is still open
- Heated chemotherapy (104-109 degrees Fahrenheit) circulated through abdominal cavity
- Duration: 60-120 minutes
- Heat enhances chemotherapy penetration and effectiveness
Why It Works
The combination addresses peritoneal mesothelioma on multiple levels:
- Surgery removes bulk disease that chemotherapy cannot penetrate
- Heat kills microscopic cancer cells and enhances drug absorption
- Direct chemotherapy delivery reaches cells that systemic chemo cannot access
- High drug concentrations possible without systemic toxicity
Survival Outcomes by Center
High-Volume Center Data (28 Years)
A study of 111 consecutive patients treated from 1993-2021 showed:
| Time Point | Median Survival |
|---|---|
| Overall cohort | 3.3 years (39.6 months) |
| If survived 1 year | 4.9 years |
| If survived 3 years | 6.1 years |
| 75th percentile | 10.6 years |
Conditional survival improves significantly for patients who reach post-operative milestones.
Australian Centre Outcomes
Data from 53 months median follow-up:
| Measure | Outcome |
|---|---|
| Median overall survival | 53 months |
| 1-year survival | 76% |
| 3-year survival | 55% |
| 5-year survival | 49% |
Survival by Completeness of Cytoreduction
The degree of tumor removal is the strongest predictor of outcomes:
| CC Score | Definition | Median Survival |
|---|---|---|
| CC-0 | No visible disease | 104 months |
| CC-1 | Residual nodules under 2.5mm | 30 months |
| CC-2 | Residual nodules 2.5mm-2.5cm | 2.7 months |
Complete cytoreduction (CC-0) achieves 8.6 years median survival.
Prognostic Factors
Tumor Burden (PCI Score)
The Peritoneal Cancer Index (PCI) measures disease extent on a 0-39 scale:
| PCI Range | Median Survival |
|---|---|
| 0-20 (low-moderate) | 103 months |
| 21-39 (high) | 33 months |
Other Significant Factors
Favorable factors:
- Complete cytoreduction (CC-0)
- Low PCI score (under 20)
- No lymph node involvement
- Epithelioid cell type
- Low proliferative index
- Negative podoplanin
Unfavorable factors:
- High PCI score
- Incomplete cytoreduction
- Lymph node metastasis
- Sarcomatoid or biphasic histology
- High proliferative markers
Cure Rates: 7+ Year Survivors
Long-term follow-up reveals that patients reaching certain milestones appear to be cured:
| Finding | Data |
|---|---|
| Cure threshold | 7+ years disease-free |
| Cure rate | 43.6% of patients |
| Conditional survival at 3 years | 6.1 years median |
Patients surviving 7 years after CRS/HIPEC have minimal risk of mesothelioma recurrence and can be considered functionally cured.
Unlike pleural mesothelioma, peritoneal mesothelioma treated with CRS/HIPEC has a real cure rate. Long-term data shows 43.6% of patients who reach 7 years appear to be cured.
Recurrence Patterns
A 2025 study in Annals of Surgical Oncology examined recurrence risk:
- Two-thirds of patients experience recurrence at some point
- Recurrence doesn’t preclude additional treatment
- Iterative CRS/HIPEC possible for selected recurrences
- Systemic chemotherapy options available
Managing Recurrence
For patients who recur:
- Repeat cytoreduction may be possible
- Second HIPEC in select cases
- Systemic immunotherapy options
- Palliative care for symptom management
Neoadjuvant Therapy: Emerging Approach
A March 2026 study showed that systemic therapy before CRS/HIPEC for high-volume disease is:
- Feasible and safe
- Similar operative times as upfront surgery
- Comparable complication rates
- May improve resectability of initially borderline cases
This approach allows some patients with higher-volume disease to become surgical candidates.
Who Is a Candidate?
Ideal Candidates
- Diagnosis confirmed as peritoneal mesothelioma
- Low to moderate tumor burden (PCI under 20)
- Good performance status (able to tolerate major surgery)
- No distant metastases
- Epithelioid cell type preferred
Relative Contraindications
- Very high tumor burden (PCI over 30)
- Poor functional status
- Significant comorbidities
- Certain tumor locations (diffuse small bowel involvement)
- Aggressive sarcomatoid histology
Assessment Process
Candidacy is determined through:
- CT/MRI imaging of abdomen and pelvis
- Possible diagnostic laparoscopy
- Assessment of tumor volume and distribution
- Pathology review of biopsy
- Cardiopulmonary evaluation
- Nutritional assessment
Recovery and Expectations
Hospital Stay
- Typical stay: 7-14 days
- ICU monitoring first 1-2 days
- Gradual return of bowel function
- Pain management required
Full Recovery
- Return to light activity: 4-6 weeks
- Full recovery: 2-3 months
- Long-term dietary modifications may be needed
- Regular follow-up imaging required
Potential Complications
CRS/HIPEC is major surgery with potential risks:
- Anastomotic leak
- Infection
- Bowel obstruction
- Kidney effects from chemotherapy
- Blood clots
- Wound healing issues
Complication rates are lower at high-volume specialized centers.
Finding a HIPEC Center
What to Look For
- High case volume (minimum 20-30 cases per year)
- Multidisciplinary team (surgical oncologist, medical oncologist, pathologist)
- Experience with mesothelioma specifically (not just other peritoneal cancers)
- Published outcomes data
Questions to Ask
- How many peritoneal mesothelioma cases have you treated?
- What is your complete cytoreduction rate?
- What is your median survival for mesothelioma specifically?
- What is your complication rate?
- Do you offer repeat surgery for recurrence?
Comparison to Other Treatments
| Treatment | Median Survival |
|---|---|
| CRS/HIPEC (complete cytoreduction) | 53-103 months |
| Systemic chemotherapy alone | 12-14 months |
| Palliative care | 6-9 months |
CRS/HIPEC offers 4-8x longer survival than chemotherapy alone for eligible patients.
What is the cure rate for CRS/HIPEC?▼
Long-term data shows 43.6% of patients who survive 7+ years after CRS/HIPEC are considered functionally cured with minimal recurrence risk. Complete cytoreduction (CC-0) achieves 104-month median survival.
How long is recovery from CRS/HIPEC?▼
Hospital stay is typically 7-14 days. Return to light activity takes 4-6 weeks, with full recovery in 2-3 months. Long-term dietary modifications may be needed.
Who is a good candidate for CRS/HIPEC?▼
Ideal candidates have peritoneal mesothelioma with low-moderate tumor burden (PCI under 20), good performance status, epithelioid cell type, and no distant metastases. A surgical evaluation at a high-volume center determines candidacy.
What if the cancer recurs after HIPEC?▼
About two-thirds of patients experience recurrence. Options include repeat cytoreduction, second HIPEC in select cases, systemic immunotherapy, and palliative care. Recurrence doesn’t preclude additional treatment.