Cytoreductive Surgery

Cytoreductive surgery (CRS) is a treatment for many gastrointestinal and abdominal cancers and those that have spread to the peritoneum (the lining around abdominal organs). It is often used in combination with a specific type of chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC), where a heated chemotherapy solution is circulated through the abdomen.

How Cytoreductive Surgery Works

The goal of cytoreductive surgery is to remove tumors and any nearby tissue where the cancer may have spread. It is often used to treat cancers in the peritoneum (the lining around abdominal organs), stomach, ovaries, appendix, liver, pancreas and colorectal organs.

CRS is usually performed as an open procedure, which requires that a long incision is made in the middle of the abdomen. The surgeon removes tumors and surrounding tissue, known as resection.

While University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC) offers the laparoscopic approach for a selected subgroup of patients, open CRS is our standard technique.

After the surgery, HIPEC is used to kill any remaining cancer cells. The abdomen is bathed in a hot chemotherapy solution for one to two hours. The whole procedure (CRS-HIPEC) takes anywhere from four to 10 hours.

The Benefits of CRS-HIPEC

CRS-HIPEC therapy has revolutionized the treatment of peritoneal cancer. The five-year survival rate for many cancers, when treated with CRS-HIPEC, is higher than traditional treatment:

For tumors that originate in the peritoneum, malignant mesothelioma had a very poor prognosis in the past with median survival of 9-14 months. Now 69 percent of patients survive after five years from receiving CRS-HIPEC.
In the case of peritoneal cancer that spread from colorectal cancer, the best systemic chemotherapy delivered similarly poor results (a median survival of less than one year). Since 2003, multiple European and North American studies have reported that about one-third of patients have no evidence of any disease recurrence after five years from receiving CRS-HIPEC therapy.
Regarding mucinous tumors (a type of ovarian cancer) and pseudomyxoma peritonei (PMP) (a rare, slow-growing tumor causing the build-up of a jelly-like substance in the abdomen), the five-year survival for patients with grade 3 disease was only 6 percent with systemic chemotherapy. Now, studies report a 50-80 percent five-year survival in grade 3 patients after receiving CRS-HIPEC therapy.
For patients with peritoneal cancer that started as ovarian cancer, studies showed improved survival, with five-year survival rate of 16.7 percent, compared favorably with the best non-surgical care with no patients surviving to five years.
In addition to higher survival rates, these patients see an improved quality of life, with dramatic improvement of abdominal distention, pain and bowel obstruction.

An international conference in 2006 was held to define the role and indications of HIPEC in colorectal cancer. UMGCCC experts participated in this conference and in its final consensus statement. According to these guidelines, CRS-HIPEC was recognized as the standard of care when colorectal cancer spreads to the peritoneum, providing that the disease is limited to the abdomen and that a complete CRS can be achieved.

UMGCCC Expertise with CRS-HIPEC

UMGCCC was among the first centers in the country to perform CRS and was actively involved in improving it. We have adopted specific techniques to reduce CRS complications.

First, we limit the number of bowel segment resections. Instead, we favor using heat to destroy the tissue with cancer cells (known as complete fulguration) when applicable, rather than resection.

We also complete the process of removing tumors before administering HIPEC, and then wait until after HIPEC to reconnect the cut portions of tissue, to prevent the chemotherapy solution from damaging the reconnected areas.

In cases where the patient's abdominal wall needs more support because of prior surgeries, hernias or the location of the tumors, we use a biomaterial mesh as a support to prevent post-surgery complications and help the abdominal wall heal.