Complex Ovarian Cancer with HIPEC: Case Study of Advanced Peritoneal Disease Management

Reviewed by

Dr. Lovedeep Singh Chauhan MS, MCh (Surgical Oncology) | Senior Surgical Oncologist Trained at Tata Memorial Hospital, Mumbai Practicing at Max Super Speciality Hospital, Mohali

Introduction

Advanced ovarian cancer is one of the most challenging cancers to treat — not because it is impossible to manage, but because it often spreads silently across the inner lining of the abdomen before it is detected. By the time many women receive a diagnosis, the disease has already reached Stage III or Stage IV, involving the peritoneum — the thin membrane that lines the abdominal cavity and covers the abdominal organs.

For years, this kind of spread was considered difficult to treat surgically. Today, a procedure called Cytoreductive Surgery combined with HIPEC (Hyperthermic Intraperitoneal Chemotherapy) has changed what is possible for carefully selected patients. Patients from across Punjab — including Ludhiana, Patiala, and Chandigarh — are now able to access this advanced treatment closer to home under the care of a trusted surgical oncologist in Punjab experienced in managing complex peritoneal surface malignancies.

This case-based overview is written to help patients, caregivers, and referring doctors understand what this treatment involves, who it is suitable for, and what the journey looks like from diagnosis to recovery.

Understanding the Disease: What Is Peritoneal Spread in Ovarian Cancer?

The peritoneum is not a single organ, it is a large surface that lines the entire inner abdomen. When ovarian cancer cells shed from the primary tumour, they can travel freely within the abdominal cavity and implant themselves on this surface, forming what are called peritoneal deposits or peritoneal carcinomatosis.

These deposits can be small — the size of a grain of sand — or large nodules covering significant portions of the bowel, liver surface, diaphragm, and pelvic organs. Because they are spread across a surface rather than confined to one organ, systemic chemotherapy alone often cannot reach them effectively enough.

This is precisely the problem that HIPEC was designed to address — delivering high-concentration heated chemotherapy directly to the peritoneal surface at the time of surgery, when the deposits have just been removed and the tissue is most accessible.

Case Overview: The Patient's Presentation

The following is a composite educational case based on the clinical pattern commonly seen in advanced ovarian cancer managed with CRS-HIPEC. All details are anonymised.

A woman in her late forties presented with a 3-month history of progressive abdominal bloating, early satiety, and dull pelvic discomfort. She had initially attributed these symptoms to a digestive problem and had been treated for gastritis at a local clinic. When the symptoms persisted and she noticed visible abdominal distension, she was referred for further evaluation.

Her CA-125 tumour marker was significantly elevated. A contrast-enhanced CT scan of the abdomen and pelvis revealed a large right ovarian mass with bilateral ovarian involvement, moderate ascites (fluid in the abdomen), and multiple peritoneal deposits across the omentum, pelvic peritoneum, and the surface of the bowel. A PET-CT confirmed no distant organ metastasis to the lungs or liver parenchyma — a critical finding that made her a potential candidate for aggressive locoregional treatment.

She was referred to Dr. Lovedeep Singh Chauhan for surgical oncology evaluation after her gynaecology team determined that the extent of peritoneal disease required a specialist in complex cancer surgery.

Staging and Workup: How Was the Extent of Disease Assessed?

Before any treatment decision was made, the patient underwent a thorough multi-disciplinary evaluation. This included:

Peritoneal Cancer Index (PCI) Scoring — A standardised tool used by surgical oncologists to map and quantify the extent of peritoneal disease across 13 abdominal regions. Each region is scored 0–3 based on the size of tumour deposits. The total PCI score helps determine whether complete surgical removal is feasible.

Nutritional and functional assessment — Major surgery like CRS-HIPEC places enormous physiological demand on the body. The patient's nutritional status, albumin levels, cardiac function, and performance status were all evaluated. Patients who are malnourished or medically frail carry significantly higher surgical risk.

Multidisciplinary Tumour Board discussion — The case was reviewed by a team including the surgical oncologist, medical oncologist, gynaecologic oncologist, radiologist, and anaesthesiologist. The decision to proceed with neoadjuvant chemotherapy followed by surgery was taken collectively, not by any single specialist alone.

Neoadjuvant chemotherapy — Given the volume of disease at presentation, the patient received 3 cycles of platinum-based chemotherapy first. This was done to reduce the tumour burden before surgery — a strategy called interval cytoreductive surgery — making complete removal more achievable and reducing surgical risk.

The Surgical Plan: What Is Cytoreductive Surgery (CRS)?

Cytoreductive surgery — also called debulking surgery — is the systematic removal of all visible peritoneal tumour deposits from the abdominal cavity. The goal is complete cytoreduction, meaning no visible tumour remains at the end of the operation. Even a small residual deposit significantly reduces the effectiveness of HIPEC.

In this case, the surgical plan included:

Total hysterectomy and bilateral salpingo-oophorectomy - Removal of the uterus, both ovaries, and fallopian tubes, which were the primary sites of disease.

Omentectomy — The omentum, a fatty apron of tissue covering the bowel, is one of the most common sites of ovarian cancer spread. Complete removal of the omentum was required.

Peritoneal stripping — Areas of the pelvic and abdominal peritoneum with visible deposits were carefully stripped away while preserving the underlying structures.

Bowel resection — A segment of the large bowel with surface involvement was resected and rejoined. Preserving bowel continuity without a permanent stoma was a planned surgical priority.

Diaphragmatic stripping — Small deposits on the right diaphragm surface were removed using electrosurgical techniques.

The entire cytoreductive portion of the operation took approximately 4 hours and achieved a completeness of cytoreduction score of CC-0 — meaning no visible residual disease — which is the benchmark for optimal surgical outcome.

What Is HIPEC and How Was It Administered?

HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy. Once cytoreduction was complete and all tumour deposits had been removed, the HIPEC phase began in the same operative sitting.

The abdominal cavity was perfused with a heated chemotherapy solution — in this case, cisplatin heated to approximately 41–43°C — circulated throughout the abdomen for 60–90 minutes using a specialised closed perfusion system. The heat serves two purposes: it directly damages cancer cells, and it enhances the penetration and cytotoxic effect of the chemotherapy drug into the remaining microscopic tissue.

The rationale is straightforward — even after the best cytoreduction, microscopic cancer cells too small to see or feel may remain on the peritoneal surface. HIPEC targets these residual cells immediately, before they have a chance to re-implant and grow.

After the HIPEC perfusion was complete, the abdomen was irrigated with saline, the chemotherapy was drained, and the abdominal closure was performed. Total operative time including CRS and HIPEC was approximately 7 hours.

Post-Operative Course: What Happened After Surgery

The patient was moved to the Intensive Care Unit (ICU) for the first 24–48 hours for close monitoring of fluid balance, kidney function, and haemodynamic stability — standard practice after major abdominal surgery of this complexity.

Key milestones in her post-operative recovery:

• Day 1–2: ICU monitoring, IV fluids, pain management, breathing exercises with physiotherapist
• Day 3: Shifted to the surgical ward, IV nutrition continued, nasogastric tube removed
• Day 4–5: Oral sips allowed, short assisted walks within the ward
• Day 7: Tolerating soft oral diet, wound clean and healing, drain outputs minimal
• Day 10: Discharged home with detailed written instructions, follow-up appointment scheduled

She was seen in follow-up at 2 weeks for wound review and pathology discussion. The final histopathology confirmed high-grade serous ovarian carcinoma with complete pathological response in several sampled sites — a result directly correlated with the neoadjuvant chemotherapy response. She was referred back to her medical oncologist for 3 further cycles of adjuvant chemotherapy to complete the treatment plan.

What the Pathology Report Showed

The histopathology report — analysed by a specialist gynaecological pathologist — provided critical information for planning the next phase of treatment. Key findings included:

Tumour type and grade — High-grade serous carcinoma, the most common and aggressive subtype of epithelial ovarian cancer.

Surgical margins — All resected specimens showed clear margins, confirming no residual tumour at the edges of removed tissue.

Lymph node status — Pelvic and para-aortic lymph nodes sampled during surgery showed no metastatic involvement.

Chemotherapy response score — Areas of the peritoneum showed evidence of treatment effect from neoadjuvant chemotherapy, scored on the standardised chemotherapy response scoring system.

[→ Read our blog on Histopathology Report Explained: What Tumor Grade, Margins, and Lymph Nodes Mean for a full breakdown of how to interpret these findings]

Who Is a Candidate for CRS-HIPEC in Ovarian Cancer?

Not every patient with advanced ovarian cancer is a suitable candidate for this procedure. Patient selection is the most critical factor in achieving good outcomes. Ideal candidates generally have:

• Peritoneal disease confined to the abdominal cavity with no distant organ metastasis
• A PCI score that suggests complete cytoreduction is achievable
• Good performance status and adequate organ function (heart, kidneys, liver)
• A tumour type that is likely to respond to intraperitoneal chemotherapy
• Adequate nutritional status and absence of severe comorbidities

Patients who are elderly, severely malnourished, have extensive disease beyond the abdomen, or have significant cardiac or renal impairment may not be suitable candidates. This decision is always made by a multidisciplinary team — never by one specialist alone.

Risks and Realistic Expectations

CRS-HIPEC is one of the most complex operations in surgical oncology. It is important that patients and families have a clear and honest understanding of what it involves.

Operative risks include prolonged anaesthesia, significant blood loss requiring transfusion, injury to adjacent organs, anastomotic leak (where a rejoined bowel segment does not heal properly), and systemic effects of the heated chemotherapy including kidney stress and temporary bone marrow suppression.

Recovery is demanding — most patients spend 10–14 days in hospital and require 6–8 weeks of careful recovery at home before returning to normal activity. Fatigue, reduced appetite, and emotional adjustment are all common in the weeks following surgery.

Long-term outcomes — For appropriately selected patients who achieve complete cytoreduction, CRS-HIPEC offers a meaningful improvement in disease-free survival and overall survival compared to chemotherapy alone. However, outcomes vary based on tumour biology, completeness of surgery, and individual patient factors. Your oncologist will discuss realistic expectations based on your specific case.

[→ Read our guide on Managing Post-Surgery Complications After Cancer Surgery for a full overview of what to watch for during recovery]

Why Specialised Surgical Expertise Matters

The outcomes of CRS-HIPEC are directly and strongly correlated with surgical experience. Centres that perform higher volumes of this procedure consistently report better completeness of cytoreduction rates, lower complication rates, and improved patient survival.

Dr. Lovedeep Singh Chauhan brings specialised training in complex surgical oncology — including peritoneal surface malignancy management — to patients across Punjab. Patients from Mohali, Ludhiana, Patiala, and across the Tricity region no longer need to travel to Mumbai or Delhi for this level of surgical expertise.

If you or a family member has been diagnosed with advanced ovarian cancer and peritoneal involvement, a consultation with a surgical oncologist experienced in CRS-HIPEC is an essential step before finalising your treatment plan.

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Disclaimer

This article is intended solely for general patient education and awareness. The case described is a composite anonymised educational overview and does not represent any single identifiable patient. No real patient names, photographs, or identifying details have been used. This content does not constitute medical advice, a diagnosis, or a treatment recommendation for any individual. Decisions regarding CRS-HIPEC or any cancer treatment must be made through direct consultation with a qualified surgical oncologist based on individual clinical assessment. Dr. Lovedeep Singh Chauhan and this website do not claim guaranteed outcomes from any surgical procedure. Results vary based on cancer type, stage, patient health, and other clinical and biological factors.