Is There a Role for HIPEC, in the Management of Ovarian Cancer

Because of the predominant intraperitoneal (IP) spread of epithelial ovarian cancer (OC), IP chemotherapy has been investigated for more than three decades, but it is not widely adopted for several reasons.It is well known that retroperitoneal disease and, with better imaging extra-abdominal disease, is present in the majority of patients with advanced OC.In addition, adhesion formation after debulking surgery prevents the equal distribution of drugs administered intraperitoneally. Furthermore, the older trials were underpowered with fewer than 200 patients enrolled, and they used different experimental arms; in some trials, other drugs were added and different dosages were given compared with those in the control arms. The largest randomized trial ever performed using IP chemotherapy was the GOG 252 trial, which was reported at the Annual Meeting of the Society of Gynecologic Oncology in 2017. In this trial, 1,560 patients were randomly assigned, with the majority (88%) of the patients presenting with stage II to III OC debulked to no or 1 cm or less residual disease. In addition to its size, the strength of this trial is that the dosages and schedule for arm I (IV carboplatin) and arm II (IP carboplatin) are the same except for the route of administration. The primary end point was PFS, and for patients with stage II to III disease with 1 cm or less residual tumor, PFS was 26.8 months for the IV carboplatin arm, 28.7 months for the IP carboplatin arm, and 27.8 months for the IP cisplatin arm. The hazard ratios for the IP carboplatin and IP cisplatin arms compared with the control arm were 0.947 (P 5 .416) and 1.01 (P 5 .727), respectively.The authors suggested that dose-dense paclitaxel might have improved efficacy to allow us to abandon IP chemotherapy.Hyperthermic intraoperative peritoneal chemotherapy (HIPEC) became a treatment option in patients with colon cancer after positive results of a randomized trial comparing surgery and HIPEC with palliative treatment alone.17 This concept for treating peritoneal metastases was then generalized to many other tumors with peritoneal carcinomatosis Despite the use of HIPEC in some centers, until recently,there was no evidence for the value of HIPEC in OC compared with conventional systemic chemotherapy options.