Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms

Practice Guideline

Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms

P. Dubé , MD * , L. Sideris , MD * , C. Law , MD § , L. Mack , MD , E. Haase , MD # , C. Giacomantonio , MD ** , A. Govindarajan , MD †† , M.K. Krzyzanowska , MD ‡‡ , P. Major , MD §§ , Y. McConnell , MD ‖‖ , W. Temple , MD , R. Younan , MD * ## , J.A. McCart , MD , †† on behalf of the Canadian HIPEC Collaborative Group

*Department of Surgery, University of Montreal, Montreal, QC.
Department of Surgery, Hôpital Maisonneuve–Rosemont, Montreal, QC.
Department of Surgery, University of Toronto, Toronto, ON.
§Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON.
Department of Surgery, University of Calgary, Calgary, AB.
#Department of Surgery, University of Alberta, Edmonton, AB.
**Department of Surgery, Dalhousie University, Halifax, NS.
††Department of Surgery, Mount Sinai Hospital, Toronto, ON.
‡‡Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON.
§§Department of Medical Oncology and Hematology, Juravinski Cancer Centre, Hamilton, ON.
‖‖Department of Surgery, University of British Columbia, Vancouver, BC.
##Department of Surgery, Centre Hospitalier de l’Université de Montréal, Montreal, QC.



To meet the needs of patients, Canadian surgical and medical oncology leaders in the treatment of peritoneal surface malignancies ( psm s), together with patient representatives, formed the Canadian HIPEC Collaborative Group ( ch i cg ). The group is dedicated to standardizing and improving the treatment of psm in Canada so that access to treatment and, ultimately, the prognosis of Canadian patients with psm are improved.

Patients with resectable psm arising from colorectal or appendiceal neoplasms should be reviewed by a multidisciplinary team including surgeons and medical oncologists with experience in treating patients with psm . Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be offered to appropriately selected patients and performed at experienced centres.

The aim of this publication is to present guidelines that we recommend be applied across the country for the treatment of psm .

KEYWORDS: Peritoneal surface malignancy , pseudomyxoma peritonei , carcinomatosis , colorectal cancer , appendiceal cancer , hyperthermic intraperitoneal chemotherapy , cytoreductive surgery , peritoneal metastasis


A peritoneal surface malignancy ( psm ) is a cancer arising from or spreading to the peritoneal surfaces. It can be a primary disease arising from the peritoneum (such as malignant peritoneal mesothelioma) or a secondary disease (such as metastasis originating from a primary malignant neoplasm). Primary psm is rare; the most frequent forms are primary peritoneal mesothelioma and serous carcinoma of the peritoneum. Secondary psm is by far the most frequent. Its origin is often cancers of the gastrointestinal tract, but it can frequently arise from ovarian cancer and breast cancer (mostly the lobular subtype). However, many cancers can metastasize to the peritoneum 17.

Surgical treatment of psm is recent 810. Before 1989, cures were anecdotal, and median survival was 9 months. Now, long-term survival is possible in 25%–85% of patients 1,2,46,8,11,12, depending on patient and disease characteristics 8,1320. Despite that success, a lack of agreement on many issues (drug, dose, duration) means that many questions remain, and few randomized controlled trials have provided comparative evidence.

In selected cases, optimal treatment of psm consists of a combination of cytoreductive surgery ( crs ) and hyperthermic intraperitoneal chemotherapy ( hipec ). This complex procedure requires a dedicated multidisciplinary team. Unfortunately, worldwide, philosophic and fundamental differences exist about issues ranging from patient selection to treatment approaches. Consequently, no accepted standard of care for the provision of this treatment has been developed.

A primary concern in the medical community regarding psm treatment by crs plus hipec is the paucity of phase iii studies to support this modern therapeutic approach. The lack of studies is, in part, a result of the strong personal biases found among surgeons providing psm care, the rapid increase in the number of centres offering this multimodal approach, and the relatively small number of patients at risk.

Well-selected psm patients can clearly be treated with crs and hipec . However, in the absence of a large body of level 1 evidence, Canadian surgical and medical oncologists should offer psm patients a thoughtful, carefully integrated approach founded in surgical and biologic principles and supported by the available evidence. To that end, it is strongly recommended that all patients with a psm from a colorectal or appendiceal neoplasm be considered for referral to one of the hipec centres listed in Table i. Referrals should occur as a first-line metastatic cancer treatment intervention.

TABLE I   Centres currently providing a hyperthermic intraperitoneal chemotherapy program in Canada


To meet the needs of patients and assure the highest possible standard of care, leading Canadian experts in the treatment of psm , together with patient representatives, formed the Canadian HIPEC Collaborative Group ( ch i cg , Appendix a ). This initiative is supported by the Colorectal Cancer Association of Canada ( and sponsorship from pharmaceutical companies.


Before these guidelines were written, the literature in PubMed was searched using the key words “peritoneal carcinomatosis,” “PC,” “intraperitoneal chemotherapy,” “HIPEC,” “colorectal neoplasms” (or cancers), “colonic neoplasms” (or cancers), “rectal neoplasms” (or cancers), “pseudomyxoma peritonei,” “debulking,” and “chemohyperthermia.” Descriptive studies and clinical trials (phase ii and iii ) published between 1990 and 2013 were retained. As additional sources of information, published guidelines from national and international organizations were obtained:

  • Society of Surgical Oncology (United States)

  • 5th International Workshop on Peritoneal Surface Malignancy (Milan, Italy; December 4–6, 2006)

  • 6th International Workshop on Peritoneal Surface Malignancy (Lyon, France; November 17–19, 2008)

  • 7th International Workshop on Peritoneal Surface Malignancy (Uppsala, Sweden; September 8–10, 2010)

  • 8th World Congress on Peritoneal Surface Malignancies (Berlin, Germany; October 31–November 2, 2012)

  • L’Association Française de Chirurgie and Direction de la lutte contre le cancer (France)

Before the final revision, a census of the available Canadian resources (any combination of expertise, equipment, and time dedicated to hipec ) was taken to align the guidelines with those resources.

Over the course of three full-day meetings and two teleconferences, surgical (PD, LS, CL, LM, EH, CG, AG, YM, WT, RY, JAM) and medical oncology (MKK, PM) experts in the treatment of psm addressed 40 questions (referenced in this paper as Q1, Q2, and so on, and detailed in Table ii). Each question was discussed by the ch i cg membership, and conclusions were based on the level of evidence and the level of consensus among the ch i cg members. The guidelines presented here focus on psm of colorectal and appendiceal origin. Questions about peritoneal mesothelioma (Q13, Q24, Q39, Q40) and other secondary sites (Q26) will be discussed in future editions of the guidelines.

TABLE II   Questions addressed during the Canadian HIPEC Collaborative Group consensus process


The evidence was graded using the five levels set out by the American Society of Clinical Oncology. Level 1 evidence is based on meta-analyses or multiple randomized trials (phase iii ). Level 2 evidence is based on 1–2 randomized trials. Level 3 evidence is based on nonrandomized trials (phase ii ). Level 4 evidence is based on observational studies, and level 5 is based on case reports or expert opinion.

The level of consensus ( loc ) concerning each question was adopted from the approach described by Murphy et al. 21 as used by the Program in Evidence-Based Medicine of Cancer Care Ontario. The loc a d definitions were determined a priori by the ch i cg members, based on a combination of the already defined levels of evidence, applicability (based on discussion and available resources), and vote of the members (Table iii).

TABLE III   Level of consensus system



Currently, 8 centres in Canada have hipec programs (Table i). All are part of an academic university centre, and all are dedicated to the development of hipec therapy in Canada.

Centres involved in hipec in Canada should be recognized and supported by hospitals, universities, provincial agencies (Q1) and national organizations (Q2). This multilevel support is needed for further development: teaching, research, accessibility, and funding ( loc a ).

The ch i cg has developed criteria based on the ch i cg loc system, as defined in this guideline, that provincial and national agencies can use to help to coordinate development, improve efficacy, and promote accessibility of hipec therapy to Canadian patients ( loc a ).

Accreditation will improve accessibility across Canada, because referring physicians will have to be convinced of the benefit of the proposed treatment before they will refer patients to ch i cg centres (Q3, loc a ).

3.1  Resources

To create viable Canadian guidelines, a census of the resources available across Canada was taken. All centres have access to computed tomography imaging and modern diagnostic equipment, but access to positron-emission tomography imaging is limited in some areas. Most teams have dedicated intraperito-neal perfusion equipment, but some use a modified extracorporeal circulation machine dedicated to cardiac surgery (an important difference, because perfusion temperature is limited to 41°C with the latter machine). Finally, drug access is not the same across Canada: The choice of chemotherapeutic and dose is limited by some authorities. Oxaliplatin is used for hipec at some sites in Canada; mitomycin C is currently available at all sites.


Multi- and interdisciplinary teams are needed for the treatment of psm patients 9,22,23. Ideally, complex psm patients should be discussed at local tumour boards ( loc a ) 24.

4.1  Team Composition

The core team is composed of surgical oncologists, anesthesiologists, perfusionists (optional), pharmacists, nurses, supportive care professionals (physiotherapists, psychologists, nutritionists, and so on), fellows and residents, pathologists, intensivists, and research personnel (nurses, research coordinator, data manager, and so on). These members should be on site and available when needed. The surgeon directs the team ( loc a ) 25. Other team members (medical oncologists, gastroenterologists, and basic scientists) are ideally on site, but if they are not, they can be part of a network to ensure services and future development.

Surgeons must have surgical oncology training, including appropriate cytoreductive surgery and hipec training (Q4, loc a ) and a surgical and research practice dedicated to psm patients. The rest of the team should have an interest in hipec , to support development and research (Q5, loc b ). The minimum number of cases handled each year per surgeon has not yet been defined, but a team or centre should handle at least 20 casesa each year ( loc b ).

Activities performed by each team should be part of the ch i cg national research program—at a minimum with respect to quality assurance and contributing to the national prospective database.

One research coordinator and operating room nurse can be identified and dedicated to the development of hipec for each local team (Q6, loc a ). The team should be recognized and supported by the institution (hospital and university) ( loc a ).


Patient selection (Table iv ) can be divided into patient-related criteria and disease-related criteria. Essentially, a patient must be fit enough to undergo a high-risk procedure, and the disease must demonstrate biologic behaviour that is potentially curable by a combination of crs and hipec 7,2634. On occasion, palliative hipec for intractable ascites can be considered 35.

TABLE IV   Absolute and relative criteria for patient eligibility


5.1  Patient-Related Criteria

Patients should not have any major comorbidities ( loc a ), and their Eastern Cooperative Oncology Group performance status at the time of hipec should be 0 ( loc a ). In selected patients, especially in those whose performance status is reversible, a performance status of 1 can be acceptable 27,36 ( loc a ).

Physiologic age should be considered (Q7). When less than 65 years of age, all eligible patients are good candidates ( loc a ). When 65 years of age and older, only carefully selected patients without comorbidities and with a low peritoneal carcinomatosis index ( pci ) (Table v ) and a low-grade tumour should be considered ( loc a ) 37,38. Body mass index should also be considered (Q8). A body mass index above 35 is a relative contraindication 39,40, and age, pci , and tumour biology should be taken into consideration ( loc b ). Patients must be motivated and must understand the extent, the risks, and the potential benefits of the procedure ( loc a ). Finally, patients should be encouraged to participate in clinical trials and to be included in the ch i cg database (Q9, loc a ).

TABLE V   Terminology


5.2  Disease-Related Criteria

Disease classification is based on the primary tumour (origin), the tumour histology (and tumour biology), and the extent of disease 11,18,31,32. Histology is documented by biopsy when feasible, because characteristics can change over time and might not match those of the primary tumour 19. Extent of disease is evaluated during the preoperative work-up, at laparoscopy in some cases, and at laparotomy.

For psm of colorectal and classical appendiceal adenocarcinoma origin 41, histology is based on differentiation. A well-differentiated classical adenocarcinoma is considered grade 1, an intermediate or moderate one is grade 2, and a poorly or undifferentiated tumour is grade 3.

For mucinous tumours of the appendix, the histologic classification is more complex and controversial, and thus multiple classifications are used. The presence of signet-ring cells in any group is a marker of a high-grade tumour (grade 3). The term pseudomyxoma peritonei is used more to describe the clinical presentation rather than the pathologic designation. Two main pathologic classifications have been described. In 1995, Ronnett et al. 42 divided these tumours into three main groups: namely, low-grade disseminated peritoneal adenomucinosis ( dpam ), high-grade peritoneal mucinous carcinomatosis ( pmca ), and intermediate-grade pmca ( pmca-i ). In 2003, Misdraji et al. 43 described another classification designating appendiceal tumours as either low-grade appendiceal mucinous neoplasms or high-grade mucinous adenocarcinomas. Knowing both of these classifications is important, because both are used in the literature. Both classifications essentially categorize appendiceal tumours into a low-grade or high-grade category. The categories are associated with different natural histories and thus different outcomes.

Extent of disease is reported using the pci 2,32,44. A pci evaluation on preoperative work-up is suboptimal, but provides an indication of whether the pci exceeds 20, which is usually a contraindication in the case of grade 1 or 2 adenocarcinomas (Q37, Q38). In certain selected cases with favourable patient and disease factors, a pci exceeding 20 can be considered, depending on the type of resection required ( loc a ). In the case of dpam and pmca-i (Q36), a high pci is not a contraindication to proceed to hipec . It is important to emphasize that, currently, pci can be accurately evaluated only at laparotomy 45.

Disease evaluation should be based on a recent work-up, which consists of

  • an appropriate history and physical examination;

  • appropriate blood tests (carcinoembryonic antigen in non-mucinous disease);

  • total colonoscopy;

  • computed tomography imaging of chest, abdomen, and pelvis 30,46,47;

  • positron-emission tomography–computed tomography imaging (if available in cases of nonmucinous disease) 47;

  • confirmation of disease (that is, pathology review, tissue biopsy, or progression on imaging); and

  • other appropriate examinations, including laparoscopy as judged necessary by the investigator 48.

5.3  The Eligible Patient

Absolute contraindications as defined by the preoperative work-up (Q10) include

  • extra-abdominal disease proven by histology 18 , b,c (Q29, Q32, Q35; loc a );

  • extraperitoneal disease, such as more than 3 liver metastases (Q28, Q31, Q34) 49, and N3 (retroperitoneal) lymph nodes (Q27, Q30, Q33)d; or

  • unknown primary tumour (Q18)e.

At the time of hipec , patients should not have signs of bowel obstruction ( loc a ), must be responding to neoadjuvant chemotherapy (if used to downstage the disease), and for adenocarcinoma, should have a tumour grade of 1 or 2 (Q22, Q23). Grade 3 adenocarcinoma (including signet-ring cells and pmca ) is a relative contraindication (Q22, Q23) 50 , f. In the case of a short interval (Q17, Q18, Q19, Q21) 46,g between the primary adenocarcinoma and peritoneal carcinomatosis (synchronous or <6 months), patients should be carefully selected, and neoadjuvant chemotherapy is strongly recommended before crs plus hipec so as to select patients who will benefit the most from this aggressive approach (for example, no development of extra-abdominal or unresectable disease) 13 ( loc b ). Patients with up to 3 liver metastases responding to neoadjuvant chemotherapy could be eligible if all other patient and disease criteria are favourable ( loc a ) 51,52.

The presence of a frozen pelvis secondary to a rectal cancer recurrence is a relative contraindication to hipec (Q25, loc a ).


Cytoreductive surgery is divided into 3 phases:

  • Assessment Phase: It is imperative to rule out extraperitoneal disease (for example, >3 liver metastases 49,51 or N3 lymph nodes 6,7,15,17,18) and to evaluate if a resection is feasible. It is during this phase that the pci is measured ( loc a ). The decision to proceed—or not—is then made 53.

  • Cytoreduction Phase: The goal is to proceed with the resection of all macroscopic disease 54. After resection, the completeness of cytoreduction ( cc ) 27,29,55 is evaluated using the cc score (Table v ).

  • HIPEC Phase: Delivery of hipec is performed, followed by creation of diverting stomas (if required). The abdomen is then closed ( loc a ). Reconstructions are performed either before or after hipec , per the surgeon’s choice ( loc a ).

6.1  Intraoperative Assessment

The goal of the intraoperative assessment is to confirm the results of the preoperative work-up and to determine the potential completeness of resection ( loc a ). A laparotomy through a xyphopubic incision optimizes exposure, and a complete adhesiolysis is mandatory to allow for a meticulous visual inspection ( loc a ). The role of laparoscopic exploration is controversial, but it can be of use when extensive miliary peritoneal carcinomatosis is suspected in the presence of a normal preoperative workup 48 ( loc b ). Intraoperative ultrasonography is not recommended (Q11, loc b ). After adhesiolysis, the pci score is calculated.

In the case of a high pci discovered at laparotomy, or when a cc0 resection is not achievable, three subsequent strategies are possible:

  • Close the abdomen and consider neoadjuvant systemic chemotherapy until the best tumour response has been achieved and then try again 56 ( loc b ). This approach is encouraged in the case of grade 1 or 2 classical adenocarcinoma, when a cc 0 resection seems hard to achieve as demonstrated by the assessment or when a very-high-risk resection seems the only way to achieve cc 0.

  • Proceed to a double cytoreduction with or without systemic chemotherapy between the procedures ( loc c ). This approach is used mainly in the case of dpam or pmca-i with a pci score exceeding 20. The goal of the first procedure is to remove all tumour from the upper or the lower abdomen; during the second procedure, the goal is to remove all remaining tumour and to proceed to the hipec phase.

  • Close the abdomen and consider best supportive care if neoadjuvant systemic chemotherapy is not an option ( loc a ).

If unexpected extraperitoneal disease is found during the exploration, the therapeutic plan must be revised ( loc b ).

In the case of classical adenocarcinoma, a cc 0 resection is required to proceed with hipec 57 ( loc a ). In the case of dpam and pmca-i originating from the appendix 58, a cc 0 resection should be the goal, but a cc 1 resection could be beneficial and might improve survival ( loc a ).

If, at any time, the situations that follow have to be considered to achieve cytoreduction, the treatment plan should be revisited by the team. A decision to go ahead with the procedure should be reserved for very motivated and highly selected patients ( loc b ). The relevant situations are

  • definitive end stoma with concomitant ileal bladder (pelvic exenteration),

  • Whipple procedure,

  • short-bowel syndrome, or

  • major hepatectomy 34,59.

6.2  CRS

Cytoreduction should be planned according to the area at risk of incomplete resection 60. The area of the abdomen at highest risk of incomplete resection should be addressed first, because it serves as an indicator—that is, the procedure should be stopped if the resection is not possible 28,61,62 ( loc b ).

In selected cases of a high pci score and dpam or pmca-i , performing the cytoreduction as two separate procedures is an option if complete cytoreduction is expected to last more than 10–15 hours, if blood loss is too high, or if surgical complications make proceeding with hipec a contraindication (Q15, loc c ). In such a situation, the infra-mesocolic area is addressed during the first surgery; the second surgery focuses on the supra-mesocolic cytoreduction and hipec . A complete adhesiolysis of the infra-mesocolic abdomen should be performed during the second procedure before hipec . An adhesiolysis of the upper abdomen can be more complex 63,64 (thus the recommendation to perform cytoreduction of the upper abdomen as the second procedure).

6.2.1  Peritonectomy

Selective peritonectomy is defined as disease-oriented peritonectomy. These procedures are selective when they are performed to remove macroscopic disease. They are indicated when a cc 0 resection is performed for an adenocarcinoma of colorectal origin or when a cc 1 resection is performed for a dpam or pmca ( loc b ).

Radical peritonectomy is defined as the resection of all parietal, diaphragmatic, and near total mesenteric peritoneum. It can be indicated when a cc 0 resection is performed for a dpam or pmca-i (Q12, loc c ).

6.2.2  Reconstruction

Bowel continuity is restored before or after hipec , per the surgeon’s preference ( loc a ). Stomas are performed after hipec ( loc b ). Anastomoses should be created according to the usual principles and surgeon’s preference ( loc a ). Hand-sewn or stapled anastomoses are acceptable ( loc a ).

Definitive stomas should be created for the usual reasons, but diverting stomas should be considered (Q15) for high-risk anastomoses such as left-sided anastomoses and low anterior resections ( loc a ).

Total gastrectomy is occasionally necessary to achieve a cc0 resection or in the case of gastric devascularization. Although a standard reconstruction with a Roux-en-Y esophagojejunostomy is generally performed, the very high risk associated with that anastomosis has to be recognized, and early re-operation and drainage should be considered if a leak occurs ( loc a ).

6.3  HIPEC

Delivery of hipec can be performed using an open or a closed technique 65. Both techniques are performed across the country and are considered safe. The highest risk for chemotherapy exposure is during clean-up, which is the same for both procedures. Whichever technique is chosen, the dose, the duration, and the temperature of perfusion should not be modified ( loc b ).

Oxaliplatin and mitomycin C are currently the most commonly used drugs. Doxorubicin, irinotecan, cisplatin, and others can be used for special indications 57,66. The recommended dose of oxaliplatin is 460 mg/m 2 perfused for 30 minutes at 43°C 44,6771 ( loc b ). Systemic 5-fluorouracil and leucovorin can be administered by the anesthetist to potentiate oxaliplatin efficacy and should be considered for classical adenocarcinoma of colorectal origin ( loc b ). The dose of 5-fluorouracil is 400–450 mg/m 2 administered over 30 minutes by the intravenous route, 30–60 minutes before hipec ( loc b ). Leucovorin (20 mg/m 2 ) is given before the 5-fluorouracil, intravenously over 10 minutes. When mitomycin C is used 14,72, the U.S. guidelines suggest 40 mg as a fixed dose to be delivered in 2 syringes 73,74 ( loc b ). Taking local habits, equipment, and funding into consideration, the ranges accepted in Canada are listed in Table vi . No concomitant systemic chemotherapy is given when mitomycin C is used for hipec ( loc a ).

TABLE VI   Administration of hyperthermic intraperitoneal chemotherapy



Overall survival varies from 20% to 90% at 5 years 70,72,7579. It is influenced 26,29,31,32,55,78 by origin of the psm , histology, pci score, patient comorbidities (performance status, body mass index, health problems), cancer-related symptoms, and surgical morbidity and mortality 79,80.

Good prognostic factors include appendiceal origin, dpam and low-grade tumours, a low pci score, and a patient who is asymptomatic and has no comorbidities 11.

Evaluation of outcomes is needed for the future development and funding of hipec programs 81. To assess outcomes, all Canadian patients should be included in a prospective database, ideally with matched tissues (normal and cancerous).

Outcomes that should be measured include complications 79,80, overall survival 2,11,28,44,57,62,69,8285, disease-free survival, quality of life 86,87, and cost-effectiveness 88.


The priority of the ch i cg research program is to maintain a national prospective database and matched-tissue tumour bank. All Canadian psm patients should be included in a database, either locally or nationally, and have tumour, normal tissue, and blood stored in a local tumour bank, if available.


9.1  Statistics

As published by the Canadian Cancer Society 89, 23,900 new colorectal cancer cases were expected in 2013, and up to 10% ( n = 2390) would be expected to have peritoneal carcinomatosis. Of the latter group, 30%–35% would be estimated to be eligible for hipec (approximately 800 patients). The incidence of pseudomyxoma peritonei ( dpam and pmca-i ) is 1 case annually per million population. In Canada, this incidence represents between 30 and 40 new cases annually, with most patients being eligible for crs plus hipec .

9.2  Accessibility

After the ch i cg census, it was estimated that the existing Canadian teams can treat 200–250 new patients annually—a number that doesn’t come close to matching the number of predicted new cases. Ideally, a national coordinating centre should be created to improve accessibility (Q16).


Given the increasing evidence that selected patients with psm can benefit from an aggressive surgical approach combined with hipec , the guidelines presented here are intended to provide the physicians who treat these patients with the necessary tools to do so. The key messages to take from these guidelines are the importance of a multidisciplinary team approach, the need for strict patient selection, early referral to a centre with expertise in the surgical management of psm , and close collaboration between medical and surgical oncologists to devise a treatment plan. It will be important to standardize the approach to these patients so that the benefits of crs and hipec can be realized across the country and so that all eligible patients have the opportunity to receive treatment.


The authors are indebted to Mr. Barry D. Stein and Ms. Filomena Servidio–Italiano of the Colorectal Cancer Association of Canada, who spearheaded the formation of the ch i cg and the writing of these guidelines. Financial support for meetings was provided by the Colorectal Cancer Association of Canada with sponsorship from Sanofi–Aventis, Amgen, Pfizer, and Belmont Instruments.


We have read and understood Current Oncology ’s policy on disclosing conflicts of interest, and we declare that we have none.


1. Schellinx ME, von Meyerfeldt MF, Sugarbaker PH. Peritoneal carcinomatosis from adenocarcinoma of the colon. Cancer Treat Res 1996;81:247–60.
cross-ref  pubmed  

2. Sugarbaker PH, Schellinx ME, Chang D, Koslowe P, Meyerfeldt M. Peritoneal carcinomatosis from adenocarcinoma of the colon. World J Surg 1996;20:585–91.
cross-ref  pubmed  

3. Jacquet P, Vidal–Jove J, Zhu B, Sugarbaker P. Peritoneal carcinomatosis from gastrointestinal malignancy: natural history and new prospects for management. Acta Chir Belg 1994;94:191–7.

4. Elias D, Raynard B, Farkhondeh F, et al. Peritoneal carcinomatosis of colorectal origin. Gastroenterol Clin Biol 2006;30:1200–4.
cross-ref  pubmed  

5. Macri A, Saladino E, Bartolo V, et al. Peritoneal carcinomatosis of colorectal origin. World J Gastrointest Oncol 2010;2:98–101.
cross-ref  pubmed  pmc  

6. Elias D, Goere D. Peritoneal carcinomatosis of colorectal origin: recent advances and future evolution toward a curative treatment. Recent Results Cancer Res 2007;169:115–22.

7. Elias D, Dubé P, Blot F, et al. Peritoneal carcinomatosis treatment with curative intent: the Institut Gustave–Roussy experience. Eur J Surg Oncol 1997;23:317–21.
cross-ref  pubmed  

8. Sugarbaker PH. Surgical treatment of peritoneal carcinomatosis: 1988 Du Pont lecture. Can J Surg 1989;32:164–70.

9. Pocard M, Boige V. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal colorectal carcinomatosis: a newly validated standard whose contribution remains to be assessed [French]. Bull Cancer 2005;92:151–4.

10. Chua TC, Moran BJ, Sugarbaker PH, et al. Early- and long-term outcome data of patients with pseudomyxoma peritonei from appendiceal origin treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Clin Oncol 2012;30:2449–56.
cross-ref  pubmed  

11. Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-Year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol 2008;15:2426–32.
cross-ref  pubmed  

12. Kusamura S, Baratti D, Zaffaroni N, et al. Pathophysiology and biology of peritoneal carcinomatosis. World J Gastrointest Oncol 2010;2:12–18.
cross-ref  pubmed  pmc  

13. Dube P, Lasser P, Elias D. Treatment of peritoneal carcinosis of colorectal origin [French]. J Chir (Paris) 1997;134:233–6.

14. Sayag–Beaujard AC, Francois Y, Glehen O, et al. Treatment of peritoneal carcinomatosis in patients with digestive cancers with combination of intraperitoneal hyperthermia and mitomycin C. Bull Cancer 2004;91:E113–32.

15. Elias D, Delperro JR, Sideris L, et al. Treatment of peritoneal carcinomatosis from colorectal cancer: impact of complete cytoreductive surgery and difficulties in conducting randomized trials. Ann Surg Oncol 2004;11:518–21.
cross-ref  pubmed  

16. Sugarbaker PH. Treatment of peritoneal carcinomatosis from colon or appendiceal cancer with induction intraperitoneal chemotherapy. Cancer Treat Res 1996;82:317–25.
cross-ref  pubmed  

17. Elias D, Detroz B, Debaene B, et al. Treatment of peritoneal carcinomatosis by intraperitoneal chemo-hyperthermia: reliable and unreliable concepts. Hepatogastroenterology 1994;41:207–13.

18. Elias D, Dubé P, Bonvalot S, et al. Treatment of liver metastases with moderate peritoneal carcinomatosis by hepatectomy and cytoreductive surgery followed by immediate post-operative intraperitoneal chemotherapy: feasibility and preliminary results. Hepatogastroenterology 1999;46:360–3.

19. Elias DM, Pocard M. Treatment and prevention of peritoneal carcinomatosis from colorectal cancer. Surg Oncol Clin N Am 2003;12:543–59.
cross-ref  pubmed  

20. Glehen O, Gilly FN, Boutitie F, et al. on behalf of the French Surgical Association. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1,290 patients. Cancer 2010;116:5608–18.
cross-ref  pubmed  

21. Murphy MK, Black NA, Lamping DL, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998;2:i–iv,1–88.

22. Elias D, Gilly FN, Boutitie F, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol 2010;28:63–8.

23. Glehen O, Cotte E, Brigand C, Arvieux C, Sayag–Beaujard AC, Gilly FN. Therapeutic innovations in the management of peritoneal carcinomatosis from digestive origin: cytoreductive surgery and intraperitoneal chemotherapy [French]. Rev Med Intern 2006;27:382–91.

24. Wright FC, De Vito C, Langer B, Hunter A on behalf of the Expert Panel on Multidisciplinary Cancer Conference Standards. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J Cancer 2007;43:1002–10.
cross-ref  pubmed  

25. Sugarbaker PH. Surgical responsibilities in the management of peritoneal carcinomatosis. J Surg Oncol 2010;101:713–24.
cross-ref  pubmed  

26. Bloemendaal AL, Verwaal VJ, van Ruth S, Boot H, Zoetmulder FA. Conventional surgery and systemic chemotherapy for peritoneal carcinomatosis of colorectal origin: a prospective study. Eur J Surg Oncol 2005;31:1145–51.
cross-ref  pubmed  

27. Sugarbaker PH. Successful management of microscopic residual disease in large bowel cancer. Cancer Chemother Pharmacol 1999;43(suppl):S15–25.
cross-ref  pubmed  

28. Elias D, Blot F, El Otmany A, et al. Curative treatment of peritoneal carcinomatosis arising from colorectal cancer by complete resection and intraperitoneal chemotherapy. Cancer 2001;92:71–6.
cross-ref  pubmed  

29. Verwaal VJ, van Tinteren H, van Ruth S, Zoetmulder FA. Predicting the survival of patients with peritoneal carcinomatosis of colorectal origin treated by aggressive cytoreduction and hyperthermic intraperitoneal chemotherapy. Br J Surg 2004;91:739–46.
cross-ref  pubmed  

30. de Bree E, Koops W, Kröger R, van Ruth S, Verwaal VJ, Zoetmulder FA. Preoperative computed tomography and selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2006;32:65–71.

31. Sugarbaker PH, Jablonski KA. Prognostic features of 51 colorectal and 130 appendiceal cancer patients with peritoneal carcinomatosis treated by cytoreductive surgery and intraperitoneal chemotherapy. Ann Surg 1995;221:124–32.
cross-ref  pubmed  pmc  

32. Sugarbaker PH, Chang D, Koslowe P. Prognostic features for peritoneal carcinomatosis in colorectal and appendiceal cancer patients when treated by cytoreductive surgery and intraperitoneal chemotherapy. Cancer Treat Res 1996;81:89–104.
cross-ref  pubmed  

33. Riss S, Mohamed F, Dayal S, et al. Peritoneal metastases from colorectal cancer: patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2013;39:931–7.
cross-ref  pubmed  

34. Elias D, Sideris L, Pocard M, et al. Results of R0 resection for colorectal liver metastases associated with extrahepatic disease. Ann Surg Oncol 2004;11:274–80.
cross-ref  pubmed  

35. Randle RW, Swett KR, Swords DS, et al. Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites. Ann Surg Oncol 2014;21:1474–9.
cross-ref  pmc  

36. Hribaschek A, Pross M, Kuhn R, et al. Prevention and treatment of peritoneal carcinomatosis in experimental investigations with CPT-11 and oxaliplatin. Anticancer Drugs 2002;13:605–14.
cross-ref  pubmed  

37. Tabrizian P, Jibara G, Shrager B, et al. Outcomes for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the elderly. Surg Oncol 2013;22:184–9.
cross-ref  pubmed  

38. Votanopoulos KI, Newman NA, Russell G, et al. Outcomes of cytoreductive surgery (crs) with hyperthermic intraperitoneal chemotherapy (hipec) in patients older than 70 years; survival benefit at considerable morbidity and mortality. Ann Surg Oncol 2013;20:3497–503.
cross-ref  pubmed  pmc  

39. McPartland SJ, Goodman MD. The effect of elevated body mass index on outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2014;21:1463–7.

40. Votanopoulos KI, Swords DS, Swett KR, et al. Obesity and peritoneal surface disease: outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for appendiceal and colon primary tumors. Ann Surg Oncol 2013;20:3899–904.
cross-ref  pubmed  pmc  

41. Marcotte E, Sideris L, Drolet P, et al. Hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from appendix: preliminary results of a survival analysis. Ann Surg Oncol 2008;15:2701–8.
cross-ref  pubmed  

42. Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH, Shmookler BM. Disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing pathologic features, site of origin, prognosis, and relationship to “pseudomyxoma peritonei.” Am J Surg Pathol 1995;19:1390–408.
cross-ref  pubmed  

43. Misdraji J, Yantiss RK, Graeme–Cook FM, Balis UJ, Young RH. Appendiceal mucinous neoplasms: a clinicopathologic analysis of 107 cases. Am J Surg Pathol 2003;27:1089–103.
cross-ref  pubmed  

44. Sugarbaker PH. Peritoneal surface oncology: review of a personal experience with colorectal and appendiceal malignancy. Tech Coloproctol 2005;9:95–103.
cross-ref  pubmed  

45. Koh JL, Yan TD, Glenn D, Morris DL. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol 2009;16:327–33.

46. Dromain C, Bisdorff A, Elias D, et al. Computed tomographic features of peritoneal carcinomatosis treated by intraperitoneal chemohyperthermia. J Comput Assist Tomogr 2003;27:327–32.
cross-ref  pubmed  

47. Dromain C, Leboulleux S, Auperin A, et al. Staging of peritoneal carcinomatosis: enhanced ct vs. pet/ct. Abdom Imaging 2008;33:87–93.

48. Pomel C, Appleyard TL, Gouy S, Rouzier R, Elias D. The role of laparoscopy to evaluate candidates for complete cytoreduction of peritoneal carcinomatosis and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2005;31:540–3.
cross-ref  pubmed  

49. Elias D, Benizri E, Pocard M, Ducreux M, Boige V, Lasser P. Treatment of synchronous peritoneal carcinomatosis and liver metastases from colorectal cancer. Eur J Surg Oncol 2006;32:632–6.
cross-ref  pubmed  

50. Van Sweringen HL, Hanseman DJ, Ahmad SA, Edwards MJ, Sussman JJ. Predictors of survival in patients with high-grade peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Surgery 2012;152:617–24.
cross-ref  pubmed  

51. Esquivel J, Sticca R, Sugarbaker P, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Ann Surg Oncol 2007;14:128–33.

52. de Cuba EM, Kwakman R, Knol DL, Bonjer HJ, Meijer GA, Te Velde EA. Cytoreductive surgery and hipec for peritoneal metastases combined with curative treatment of colorectal liver metastases: systematic review of all literature and meta-analysis of observational studies. Cancer Treat Rev 2013;39:321–7.

53. Elias D, Benizri E, Vernerey D, Eldweny H, Dipietrantonio D, Pocard M. Preoperative criteria of incomplete resectability of peritoneal carcinomatosis from non-appendiceal colorectal carcinoma. Gastroenterol Clin Biol 2005;29:1010–13.

54. Cintron JR, Pearl RK. Colorectal cancer and peritoneal carcinomatosis. Semin Surg Oncol 1996;12:267–78.
cross-ref  pubmed  

55. Verwaal VJ, Boot H, Aleman BM, van Tinteren H, Zoetmulder FA. Recurrences after peritoneal carcinomatosis of colorectal origin treated by cytoreduction and hyperthermic intraperitoneal chemotherapy: location, treatment, and outcome. Ann Surg Oncol 2004;11:375–9.
cross-ref  pubmed  

56. Sugarbaker PH, Bijelic L, Chang D, Yoo D. Neoadjuvant folfox chemotherapy in 34 consecutive patients with mucinous peritoneal carcinomatosis of appendiceal origin. J Surg Oncol 2010;102:576–81.
cross-ref  pubmed  

57. Elias D, Lefevre JH, Chevalier J, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol 2009;27:681–5.

58. Sideris L, Mitchell A, Drolet P, Leblanc G, Leclere YE, Dubé P. Surgical cytoreduction and intraperitoneal chemotherapy for peritoneal carcinomatosis arising from the appendix. Can J Surg 2009;52:135–41.
pubmed  pmc  

59. Elias DM. Peritoneal carcinomatosis or liver metastases from colorectal cancer: similar standards for a curative surgery? Ann Surg Oncol 2004;11:122–3.
cross-ref  pubmed  

60. Matsuda K, Hotta T, Takifuji K, et al. Clinical impact of a macroscopically complete resection of colorectal cancer with peritoneal carcinomatosis. Surgery 2012;151:238–44.

61. Maggiori L, Elias D. Curative treatment of colorectal peritoneal carcinomatosis: current status and future trends. Eur J Surg Oncol 2010;36:599–603.
cross-ref  pubmed  

62. Verwaal VJ. Cytoreduction and hipec for peritoneal carcinomatosis from colorectal origin: the Amsterdam experience. Acta Chir Belg 2006;106:283–4.

63. Hildebrandt B, Rau B, Gellermann J, Wust P, Reiss H. Hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinosis. J Clin Oncol 2004;22:1527–9.
cross-ref  pubmed  

64. Knorr C, Reingruber B, Meyer T, Hohenberger W, Stremmel C. Peritoneal carcinomatosis of colorectal cancer: incidence, prognosis, and treatment modalities. Int J Colorectal Dis 2004;19:181–7.

65. Glehen O, Cotte E, Kusamura S, et al. Hyperthermic intraperitoneal chemotherapy: nomenclature and modalities of perfusion. J Surg Oncol 2008;98:242–6.
cross-ref  pubmed  

66. Elias D, Benizri E, Di Pietrantonio D, Menegon P, Malka D, Raynard B. Comparison of two kinds of intraperitoneal chemotherapy following complete cytoreductive surgery of colorectal peritoneal carcinomatosis. Ann Surg Oncol 2007;14:509–14.

67. Elias D, Bonnay M, Puizillou JM, et al. Heated intra-operative intraperitoneal oxaliplatin after complete resection of peritoneal carcinomatosis: pharmacokinetics and tissue distribution. Ann Oncol 2002;13:267–72.
cross-ref  pubmed  

68. Elias D, El Otmany A, Bonnay M, et al. Human pharmacokinetic study of heated intraperitoneal oxaliplatin in increasingly hypotonic solutions after complete resection of peritoneal carcinomatosis. Oncology 2002;63:346–52.
cross-ref  pubmed  

69. Elias D, Pocard M, Goere D. hipec with oxaliplatin in the treatment of peritoneal carcinomatosis of colorectal origin. Cancer Treat Res 2007;134:303–18.

70. Elias D, Sideris L, Pocard M, et al. Efficacy of intraperitoneal chemohyperthermia with oxaliplatin in colorectal peritoneal carcinomatosis. Preliminary results in 24 patients. Ann Oncol 2004;15:781–5.
cross-ref  pubmed  

71. Elias DM, Sideris L. Pharmacokinetics of heated intraoperative intraperitoneal oxaliplatin after complete resection of peritoneal carcinomatosis. Surg Oncol Clin N Am 2003;12:755–69,xiv.
cross-ref  pubmed  

72. Shen P, Hawksworth J, Lovato J, et al. Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy with mitomycin C for peritoneal carcinomatosis from non-appendiceal colorectal carcinoma. Ann Surg Oncol 2004;11:178–86.
cross-ref  pubmed  

73. de Bree E, Witkamp AJ, Zoetmulder FA. Intraperitoneal chemotherapy for colorectal cancer. J Surg Oncol 2002;79:46–61.
cross-ref  pubmed  

74. Sugarbaker PH, Stuart OA, Vidal–Jove J, Pessagno AM, DeBruijn EA. Pharmacokinetics of the peritoneal–plasma barrier after systemic mitomycin C administration. Cancer Treat Res 1996;82:41–52.

75. Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol 2004;22:3284–92.
cross-ref  pubmed  

76. Sugarbaker PH. Evolution of cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis: are there treatment alternatives? Am J Surg 2011;201:157–9.

77. Chua TC, Liauw W, Saxena A, et al. Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy. Am J Surg 2011;201:149–56.

78. Verwaal VJ, Zoetmulder FA. Follow-up of patients treated by cytoreduction and chemotherapy for peritoneal carcinomatosis of colorectal origin. Eur J Surg Oncol 2004;30:280–5.
cross-ref  pubmed  

79. Haslinger M, Francescutti V, Attwood K, et al. A contemporary analysis of morbidity and outcomes in cytoreduction/hyperthermic intraperitoneal chemoperfusion. Cancer Med 2013;2:334–42.
cross-ref  pubmed  pmc  

80. Younan R, Kusamura S, Baratti D, et al. Bowel complications in 203 cases of peritoneal surface malignancies treated with peritonectomy and closed-technique intraperitoneal hyperthermic perfusion. Ann Surg Oncol 2005;12:910–18.
cross-ref  pubmed  

81. Zenasni F, Botella M, Elias D, et al. The long-term impact of hyperthermic intraperitoneal chemotherapy on survivors treated for peritoneal carcinomatosis: a cross-sectional study. Support Care Cancer 2009;17:1255–61.
cross-ref  pubmed  

82. Elias D, Raynard B, Boige V, et al. Impact of the extent and duration of cytoreductive surgery on postoperative hematological toxicity after intraperitoneal chemohyperthermia for peritoneal carcinomatosis. J Surg Oncol 2005;90:220–5.
cross-ref  pubmed  

83. Glehen O, Cotte E, Schreiber V, Sayag–Beaujard AC, Vignal J, Gilly FN. Intraperitoneal chemohyperthermia and attempted cytoreductive surgery in patients with peritoneal carcinomatosis of colorectal origin. Br J Surg 2004;91:747–54.
cross-ref  pubmed  

84. Verwaal VJ, van Ruth S, Witkamp A, Boot H, van Slooten G, Zoetmulder FA. Long-term survival of peritoneal carcinomatosis of colorectal origin. Ann Surg Oncol 2005;12:65–71.
cross-ref  pubmed  

85. Gervais MK, Dubé P, McConnell Y, Drolet P, Mitchell A, Sideris L. Cytoreductive surgery plus hyperthermic intra-peritoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from colorectal cancer. J Surg Oncol 2013;108:438–43.
cross-ref  pubmed  

86. McQuellon RP, Loggie BW, Fleming RA, Russell GB, Lehman AB, Rambo TD. Quality of life after intraperitoneal hyperthermic chemotherapy (iphc) for peritoneal carcinomatosis. Eur J Surg Oncol 2001;27:65–73.
cross-ref  pubmed  

87. Chua TC. Progress in the combined modality management of peritoneal carcinomatosis. J Surg Oncol 2010;102:728–9.
cross-ref  pubmed  

88. Bonastre J, Chevalier J, Elias D, et al. Cost-effectiveness of intraperitoneal chemohyperthermia in the treatment of peritoneal carcinomatosis from colorectal cancer. Value Health 2008;11:347–53.
cross-ref  pubmed  

89. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2013. Toronto, ON: Canadian Cancer Society; 2013. [Available online at:; cited February 16, 2014]



Spearheaded by the Colorectal Cancer Association of Canada, the Canadian HIPEC Collaborative Group ( ch i cg ) is a national network of interdisciplinary health professionals, patient advocates, and dedicated partners whose mission is to improve the lives of patients with peritoneal surface malignancy ( psm ) by improving the accessibility of, and advancing the standard of care for, treatment involving hyperthermic intraperitoneal chemotherapy ( hipec ). The ch i cg is dedicated to awareness, education, standards, research, and development of hipec treatment in Canada through our mission objectives.

Mission Objectives

  • Creation of an interdisciplinary clinical pathway and dedicated network for the management of psm patients

  • Creation and maintenance of uniformity within and among Canadian institutions as it relates to the determination of quantitative prognostic indicators in psm patient selection and case management

  • Development and maintenance of a national database and research program to assist with the determination of optimal treatment options for patients with psm

  • Development and maintenance of standards based on current evidence, and evaluation of best practices


The ch i cg coordinating committee ( ch i cg - cc ) comprises one representative from each accredited Canadian team, plus one representative of the business committee. The ch i cg - cc is responsible for scientific and strategic planning, and coordinates subcommittees on accessibility; data and tissue banking; standardization and guidelines review; basic and preclinical research; phase i , ii , and iii trials; technology evaluation; and quality control and audit.

Correspondence to: J. Andrea McCart, Mount Sinai Hospital, 1225–600 University Avenue, Toronto, Ontario M5G 1X5. E-mail:

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aThis recommendation is based on recent recommendations from the Peritoneal Surface Oncology Group International. A new team should be handling at least 1 case each month, with the goal of treating 20 patients each year. Until a new team has the referral base to handle 1 case per month, consideration should be given to referring those patients to an existing centre. ( Return to Text )

bAppropriate selection of patients is key and must be based on histopathologic examination. All material related to the current episode must be reviewed, and appendiceal adenocarcinoma must be classified according to a recognized classification system ( loc b ). ( Return to Text )

cFor example, supraclavicular nodes or histology-proven lung metastasis. If histology is not possible, reassessment over a 2- to 3-month period of observation with or without chemotherapy is a good option ( loc b ). ( Return to Text )

dIf clearly not peritoneal carcinomatosis. ( Return to Text )

eIn the case of dpam or pmca-i , the patient is eligible for debulking plus hipec even if the primary is unknown, and chances of cure are good. In most patients, even women, the primary is the appendix. ( Return to Text )

fIn highly selected grade 3 cases, if other factors are favourable, hipec can be considered ( loc b ). ( Return to Text )

gIn the presence of dpam , pmca-i , or appendiceal adenocarcinoma grade 1 or 2, the primary tumour can be addressed at the same time as the peritoneal carcinomatosis ( loc b ). ( Return to Text )

Current Oncology , VOLUME 22 , NUMBER 2 , April 2015

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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)