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Cytoreductive Surgery and HIPEC for Colorectal Cancer: Facing the Facts and Addressing the Issues to Allow for Widespread Acceptance

Melissa Teo Ching Ching and Grace Tan Hwei Ching

60% of colorectal cancers are diagnosed at an advanced stage. Curative strategies involving multimodality treatment with surgical resection and chemotherapy have been employed for liver and lung metastases from colorectal cancer. Peritoneal metastases are diagnosed synchronously in 10-15% of all newly diagnosed colorectal cancer, and in 40-70% of patients who suffer a recurrence. They are the sole sites of metastases in 10-30% of these cases. An understanding of peritoneal metastases must take into consideration the following:

1. Peritoneal metastases do not respond to systemic chemotherapy in the same fashion as liver and lung metastases

2. Peritoneal disease causes many local problems, resulting in disruption of planned chemotherapy

3. CRS and HIPEC actually works for peritoneal disease and

4. Peritoneal disease is usually not detected on state-of-the-art imaging modalities.

Despite mounting evidence of the effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) at prolonging survival in selected patients with colorectal peritoneal carcinomatosis, there remains a reluctance to explore this combined treatment modality. This is likely to be a result of the perceived morbidity and mortality of such a procedure, with most medical oncologists and colorectal surgeons being unfamiliar with the combined treatment. As with all complex procedures, a learning curve is observed, with proficiency likely only after 25 cases and at a high volume centre, with more than 30 cases annually.An effective management strategy employing CRS and HIPEC for selected patients with colorectal peritoneal carcinomatosis can only be achieved if a concerted effort is made to understand this disease and address the concerns regarding this treatment.