HIPEC for Ovarian Cancer, Keyhole Surgery and Sentinel Nodes

HIPEC (hyperthermic intraperitoneal chemotherapy) is heated chemotherapy circulated through the abdomen during surgery, after the surgeon has removed all visible tumour. For advanced ovarian cancer it has, in the words of Dr. Archit Pandit, Director Surgical Oncology, Fortis Escorts, Okhla, New Delhi, India, come as a game changer, improving both progression-free and overall survival in women once considered beyond treatment.

HIPEC is one half of the surgical story. The other is the steady move from open surgery to laparoscopic and robotic cancer surgery, refined by sentinel lymph node mapping and fertility-sparing techniques. This article explains both, the patients each suits, and the limits Dr. Pandit draws around them. For the wider picture, including the four gynaecological cancers and the red flags that should trigger a referral, see the complete guide to advanced treatments in gynaecologic oncology.

Why advanced ovarian cancer needed a new approach

Ovarian cancer is usually diagnosed late. The ovary sits in a large space within the abdomen, where a tumour can grow for a long time before it causes symptoms. By the time most women are diagnosed, the cancer is at stage 3C or stage 4: it has spread across the peritoneum, the thin membrane that lines the abdominal cavity and covers the bowel and other organs, or beyond the abdomen.

Dr. Pandit was candid about what that used to mean. Patients diagnosed at this stage were frequently neglected, and for many there was no effective treatment to offer. Over the last 10 to 15 years, HIPEC has moved to the forefront. His team now treats stage 3C and some stage 4 ovarian cancers with it, and he has seen what he describes as tremendous improvement in certain ovarian cancers.

How HIPEC for ovarian cancer works: surgery, then heated chemotherapy

In ovarian cancer, HIPEC is not a stand-alone treatment. It is the second step of a single operation that begins with cytoreductive surgery (CRS).

Step 1: cytoreductive surgery removes the visible disease

When the surgeon opens the abdomen, the gross disease is visible: tumour deposits on the peritoneum, the omentum (the fatty apron of tissue that hangs from the stomach over the bowel) and the surfaces of other organs. Cytoreductive surgery means removing all of it. As Dr. Pandit put it, what can be seen with the naked eye is removed. Only once the macroscopic disease is gone does HIPEC begin.

Step 2: heated chemotherapy treats the microscopic disease

What the eye cannot see, the microscopic disease, is the target of HIPEC. Chemotherapy is heated to 41 to 43 degrees Celsius and circulated inside the abdomen for 60 to 90 minutes while the operation continues.

A dedicated HIPEC machine drives the circulation. The chemotherapy runs from the patient's abdomen to the machine, back into the abdomen and back to the machine again in a continuous loop, with the temperature controlled throughout.

The evidence on survival

Dr. Pandit stresses that HIPEC does not merely delay recurrence. In stage 3 ovarian cancer operated on after neoadjuvant chemotherapy, adding HIPEC to interval cytoreductive surgery improved both progression-free survival (the time before the cancer grows again) and overall survival (how long patients live) in a randomised trial. His team has been performing CRS with HIPEC for around 15 to 20 years.

HIPEC eligibility: which cancers it treats, and which it does not

HIPEC is a treatment for cancers that spread across the peritoneum. Dr. Pandit lists six in which it is used:

1. Ovarian cancer, the most frequent indication
2. Primary peritoneal cancer
3. Appendiceal cancer
4. Colon cancer
5. Rectal cancer
6. Some stomach cancers

The strength of evidence differs across these. In peritoneal spread from colorectal cancer, most of the benefit comes from complete cytoreductive surgery; the PRODIGE 7 trial found no survival gain from adding oxaliplatin HIPEC.

Among gynaecological cancers, he names ovarian and endometrial cancer as the only two in which HIPEC can be used. For endometrial cancer, HIPEC remains investigational and is not part of standard treatment guidelines; its established role in gynaecology is in ovarian cancer.

HIPEC is not a treatment for cervical cancer

A doctor in the session asked whether HIPEC, or another technology, could be used for a patient with stage 2 cervical cancer. Dr. Pandit's answer was an unequivocal no: HIPEC is not for cervical cancer. Early cervical cancer is treated with surgery. From stage 2B onwards, his approach is chemotherapy with radiation, followed in some cases by immunotherapy. Stage 2B means the tumour has spread beyond the cervix into the tissue alongside the uterus; by this stage concurrent chemoradiation, rather than surgery, is the standard treatment.

HIPEC cost in India

Dr. Pandit put the cost of cytoreductive surgery with HIPEC at Fortis at around $11,000 to $12,000. The Jivo Healthcare page on CRS and HIPEC costs gives broader benchmarks.

Minimally invasive cancer surgery: open to keyhole to robotic

Minimally invasive surgery is the second major surgical advance in gynaecological cancer care. Dr. Pandit describes the path in three stages: surgery began as open surgery, moved to laparoscopic (keyhole) cancer surgery, and now includes robotic cancer surgery, in which the surgeon controls wristed instruments from a console.

India has performed laparoscopic and robotic-assisted cancer surgery for about two decades. Dr. Pandit's team has performed laparoscopic cancer surgery for around 20 years, and robotic surgery since 2021.

The advantages Dr. Pandit sees

Against open surgery, he lists the benefits of robotic and laparoscopic cancer surgery as:

• Smaller incisions and better outcomes.
• Equally good oncological clearance, meaning the cancer is removed as completely as with open surgery.
• Less morbidity (fewer complications) and lower mortality.
• Less post-operative pain, both acute and chronic.
• Shorter hospital stays and fewer days in intensive care.
• A faster return to normal life and work, which he points out matters because most patients, women and men alike, now work and need to get back to it.

Which operations are done minimally invasively

Dr. Pandit's team uses robotic and laparoscopic approaches for retroperitoneal lymph node dissection (removal of the lymph nodes at the back of the abdomen), radical hysterectomy, pelvic lymph node dissection and complex endometriosis surgery. His team uses the laparoscopic approach in endometrial cancer, sometimes in early cervical cancer, and in early ovarian cancer.

The approach for early cervical cancer needs careful selection. A large randomised trial published in 2018 (the LACC trial) found that minimally invasive radical hysterectomy for early cervical cancer led to higher recurrence and lower survival than open surgery, and international guidelines now treat open radical hysterectomy as the standard approach for most women with early cervical cancer. Dr. Alka Dahiya's guide to robotic surgery in gynaecologic oncology discusses patient selection for robotic cancer surgery in more depth.

Teaching the technique

Dr. Pandit teaches laparoscopic radical hysterectomy widely. His surgical video demonstrating a safe dissection for radical hysterectomy has been viewed more than 100,000 times on his YouTube channel and has been used in teaching at medical colleges. His team also runs fellowship programmes for gynaecologists who want to learn laparoscopic radical hysterectomy and laparoscopic hysterectomy.

Sentinel lymph node mapping with ICG: one node instead of all

Dr. Pandit counts sentinel lymph node dissection among the major advances in gynaecological cancer surgery. The sentinel node is the first lymph node to which a tumour drains, and therefore the node most likely to contain spread.

Until recently, surgery for many endometrial and cervical cancers included removal of all the pelvic lymph nodes, a full pelvic lymphadenectomy. That carries a real burden of side effects. With sentinel lymph node mapping, the surgeon identifies the one node to which the tumour spreads, removes it and examines it, instead of removing all the other nodes. His team uses indocyanine green (ICG), a fluorescent dye that is injected into the cervix and travels to the sentinel node, where it glows under near-infrared light on the surgical camera.

Fertility-sparing surgery for early-stage cancers

For young women with early-stage cancers, Dr. Pandit's team performs fertility-sparing surgery, preserving fertility by not removing the uterus or the ovaries. These options exist only for early-stage disease, which is one more reason early referral matters.

Dr. Pandit sums up the combined effect of minimally invasive surgery, sentinel node mapping and fertility-sparing techniques simply: complications have fallen and hospital stays have become shorter.

Minimally invasive surgery beyond the pelvis

The same minimally invasive principle applies when a gynaecological cancer has spread. Dr. Pandit described a woman whose ovarian germ cell tumour (a tumour arising from the egg-forming cells) had spread to the lung. Instead of opening the chest, the team removed the affected part of the lung by video-assisted thoracoscopic surgery (VATS), through small holes in the chest. Patients who undergo this kind of surgery typically go home within four to five days.

Cost of laparoscopic cancer surgery and sentinel node mapping

Dr. Pandit put laparoscopic cancer surgery, such as laparoscopic radical hysterectomy, at usually about $5,000 to $5,500, and robotic or laparoscopic cancer surgery with lymph node dissection or sentinel node mapping at about $5,000, rising to $6,500 to $7,000; the full table of his figures is in the complete guide, and broader benchmarks are on the Jivo Healthcare page for radical hysterectomy costs.

The diagnostic and medical advances that decide who needs which operation, from BRCA testing to immunotherapy, are covered in the companion article on genetic testing, targeted therapy and HPV vaccination. Doctors' questions on HIPEC eligibility and cost, with Dr. Pandit's full answers, are in the Live Discussion.