HIPEC

HIPEC (CRS-HIPEC)
Cytoreductive Surgery + Heated Intraperitoneal Chemotherapy for Peritoneal Mesothelioma
Combined With	Cytoreductive surgery (CRS)
Heated To	41 to 43 °C
Perfusion Duration	60 to 90 minutes
Preferred HIPEC Agents	Cisplatin + doxorubicin (2025 consensus)
PCI Threshold	PCI ≤ 20 (preferred)
Strongest Histologic Indication	Epithelioid subtype
Operative Time (Typical)	6 to 12+ hours
30-Day Mortality (Expert Centers)	0 to 2.1%
Lead Outcome Anchor	84.6% 5-yr OS (French multicentric, n=270 upfront-resectable, 2026)
First Pioneered By	Paul Sugarbaker, MD (Washington Cancer Institute)

HIPEC for Peritoneal Mesothelioma: Procedural Reference

Executive Summary

HIPEC — hyperthermic intraperitoneal chemotherapy — is the heated chemotherapy half of a combined treatment called CRS-HIPEC (cytoreductive surgery with hyperthermic intraperitoneal chemotherapy), which is the established standard of care for resectable peritoneal mesothelioma. The procedure is performed in two stages on the same operative day: surgeons first remove all visible tumor through extensive peritonectomy and organ-surface stripping, then perfuse the abdominal cavity with a heated chemotherapy solution at 41 to 43 °C for 60 to 90 minutes to kill microscopic residual disease.

The single most important determinant of outcome is the completeness of cytoreduction (CC) score assigned at the end of surgery — a CC-0 result (no visible residual disease) is the goal, and failure to achieve CC-0 or CC-1 substantially worsens prognosis. The second most important determinant is the Peritoneal Cancer Index (PCI), a 0–39 quantitative score of disease extent measured intraoperatively across 13 abdominopelvic regions; most expert centers use PCI ≤ 20 as the surgical-candidacy threshold. Histology matters as much as either: epithelioid disease has the strongest CRS-HIPEC indication, biphasic is individualized, and pure sarcomatoid is generally not a candidate.

Outcomes at high-volume centers in upfront-resectable patients are unprecedented for peritoneal mesothelioma. The 2026 French multicentric experience covering 924 patients reported a 5-year overall survival of 84.6 percent in the upfront-resectable subgroup (n=270), with 30-day operative mortality of 0 to 2.1 percent at expert centers and Clavien-Dindo grade III or higher major morbidity around 30 to 51 percent. The 2025 international consensus (Brown et al., Ann Surg Oncol) and the March 2025 India consensus exercise both endorse CRS-HIPEC as the standard of care for newly diagnosed, completely-resectable peritoneal mesothelioma without contraindications.

This page is the procedural reference: it covers what HIPEC is, how CRS-HIPEC is performed, who qualifies, what HIPEC chemotherapy agents are used, what to expect through pre-operative, intra-operative, and recovery phases, the complication profile, the 2025–2026 consensus framework, and institutional-volume considerations. Stage-stratified survival data, treatment-pathway comparisons, and trial outcomes data live at Mesothelioma_Prognosis and Peritoneal_Mesothelioma; the 84.6% lead anchor in this page sets context only, and detailed survival figures are not repeated here.

At a Glance

• CRS-HIPEC is two procedures, one operative day — Cytoreductive surgery (extensive peritonectomy + organ-surface stripping to achieve no visible residual disease) immediately followed by intraperitoneal perfusion with heated chemotherapy at 41 to 43 °C for 60 to 90 minutes.
• Standard of care for resectable peritoneal mesothelioma — The 2025 international consensus and the March 2025 India consensus exercise both endorse CRS-HIPEC as the standard of care when disease is completely resectable and the patient has no contraindication to surgery.
• Surgical candidacy gates on three variables — Histology (epithelioid strongest; biphasic individualized; sarcomatoid generally excluded), PCI (≤ 20 preferred at most centers; up to 30 at selected ultra-high-volume centers in epithelioid cases), and performance status (ECOG 0–1).
• Cisplatin + doxorubicin is the preferred HIPEC combination — The 2025 international consensus achieved strong agreement on cisplatin–doxorubicin for routine peritoneal mesothelioma HIPEC; mitomycin C and carboplatin remain alternatives at some centers.
• Lead outcome anchor: 84.6% 5-year OS in upfront-resectable disease — The 2026 French multicentric experience (n=924; n=270 upfront-resectable subgroup) is the current benchmark for what an optimally-staged, expert-center CRS-HIPEC program delivers.
• Expert-center 30-day mortality is 0 to 2.1% — Across modern multicenter series, perioperative mortality is now low at high-volume centers; major morbidity (Clavien-Dindo grade III or higher) is around 30 to 51 percent.
• Pioneered by Paul Sugarbaker, MD — Systematic CRS-HIPEC for peritoneal surface malignancies was developed by Dr. Sugarbaker at the Washington Cancer Institute; PSOGI formally established it as standard of care for resectable peritoneal mesothelioma at the Milan international consensus in 2006.
• Diagnostic laparoscopy is now standard before committing to full CRS-HIPEC — Laparoscopy allows accurate PCI scoring, assessment of mesenteric and small-bowel disease, and identification of patients in whom complete cytoreduction is not achievable, avoiding futile laparotomy.

Key Facts

Metric	Finding
HIPEC temperature window	41 to 43 °C
Perfusion duration	60 to 90 minutes
Preferred HIPEC agents (2025 consensus)	Cisplatin + doxorubicin
PCI candidacy threshold	≤ 20 (preferred); up to 30 at selected centers in epithelioid
CC-0 (complete cytoreduction)	No visible residual disease — primary surgical target
Strongest histologic indication	Epithelioid subtype
ECOG performance status	0 to 1
Typical operative time	6 to 12+ hours
30-day operative mortality (expert centers)	0 to 2.1 percent
Major morbidity (Clavien-Dindo ≥ III)	~30 to 51 percent
Lead outcome anchor (5-yr OS, upfront-resectable)	84.6 percent (French multicentric 2026, n=270)
Standard-of-care endorsement	Brown et al., Ann Surg Oncol 2025; March 2025 India consensus

What Is HIPEC, and What Is CRS-HIPEC?

HIPEC stands for hyperthermic intraperitoneal chemotherapy — chemotherapy drugs delivered directly into the abdominal cavity, heated to 41 to 43 °C, and circulated for 60 to 90 minutes. Patients rarely receive HIPEC by itself; the standard treatment is the combined procedure CRS-HIPEC, in which surgeons first physically remove all visible tumor through cytoreductive surgery and then immediately perfuse the abdomen with the heated chemotherapy solution to kill any microscopic disease the surgical step could not reach.

The clinical rationale for combining surgery with intraperitoneal heated chemotherapy is straightforward. Peritoneal mesothelioma spreads across the peritoneal lining as nodules and plaques rather than as a single resectable mass, which means that even an aggressive surgical resection will leave behind microscopic disease that systemic intravenous chemotherapy struggles to reach (the peritoneum has limited blood supply and the peritoneal-plasma barrier limits drug penetration from the bloodstream). Delivering chemotherapy directly into the peritoneal cavity raises local drug concentrations dramatically while limiting systemic toxicity, and heating the solution adds a hyperthermic kill mechanism on top of the chemotherapeutic effect.

The proposed mechanisms of hyperthermia include direct cytotoxicity at temperatures above 41 °C, enhanced platinum–DNA adduct formation that potentiates cisplatin activity, impairment of DNA repair in tumor cells, and improved drug penetration into peritoneal tissues. A 2025 porcine model study found no statistically significant difference in cisplatin tissue concentrations between hyperthermic and normothermic intraperitoneal chemotherapy in cancer-free animals, but tumor microenvironments differ from healthy peritoneum and the clinical superiority of hyperthermia over normothermia has not been formally established in randomized trials. Despite the open mechanistic question, the cumulative non-randomized evidence from multi-decade institutional series anchors hyperthermic delivery as the current standard.

CRS-HIPEC was systematically pioneered by Paul H. Sugarbaker, MD at the Washington Cancer Institute, and the Peritoneal Surface Oncology Group International (PSOGI) formally established it as standard of care for resectable peritoneal mesothelioma at the Milan international consensus in 2006. The 2025 international consensus (Brown et al., Ann Surg Oncol) and the March 2025 India consensus exercise both reaffirm that endorsement.

The CRS-HIPEC Procedure

Phase 1: Cytoreductive Surgery (CRS)

CRS is an extensive abdominal operation aimed at removing all visible tumor — the surgical goal is CC-0 (no visible residual disease) or CC-1 (≤ 2.5 mm residual, considered penetrable by HIPEC). Procedures routinely combined within a single CRS operation include:

• Parietal peritonectomy (stripping the peritoneal lining off the abdominal wall)
• Visceral peritonectomy (stripping the peritoneal lining off organs)
• Greater and lesser omentectomy
• Cholecystectomy
• Splenectomy (if involved)
• Enterectomy or partial colectomy (if bowel involvement)
• Diaphragmatic stripping (if diaphragmatic disease present)
• Partial hepatic capsule stripping (if liver-surface involvement)

CRS is one of the longest-duration cancer operations performed in modern practice. Operative times typically range from 6 to 12+ hours, with single-institution series averaging in the high-500-minute range for upfront cases. Surgeons proceed methodically through each abdominal quadrant, removing visible tumor and the involved peritoneal surface beneath it, with intermittent reassessment of the Peritoneal Cancer Index. Some centers use intraoperative laparoscopy or open inspection partway through the procedure to confirm that complete cytoreduction is achievable; if at any point the surgical team determines CC-0 or CC-1 cannot be reached, CRS may be aborted before the chemotherapy phase, sparing the patient HIPEC toxicity in a procedure unlikely to confer survival benefit.

Phase 2: HIPEC Delivery

Immediately after CRS — without closing the abdomen first, in the most common technique — the abdominal cavity is perfused with a chemotherapy solution heated to 41 to 43 °C and circulated for 60 to 90 minutes. Two delivery techniques exist:

• Open ("coliseum") technique — Abdominal wall held open with a self-retaining retractor system; perfusion fluid circulates within a temporary plastic enclosure. The surgeon manually agitates the abdominal contents during perfusion to improve drug distribution. This technique allows direct manual mixing but exposes operating-room staff to chemotherapeutic vapor.
• Closed technique — Abdomen temporarily closed with skin sutures or a sealed device; perfusion fluid circulates through inflow and outflow catheters. This technique reduces staff chemotherapy exposure but limits manual agitation.

No randomized evidence demonstrates the superiority of either technique in peritoneal mesothelioma specifically; the choice typically reflects institutional preference and infrastructure.

Optional Adjuncts: NIPEC and EPIC

Some centers extend regional chemotherapy beyond the single intraoperative HIPEC perfusion:

• NIPEC (normothermic intraperitoneal chemotherapy) — Same intraperitoneal delivery without hyperthermia, sometimes used as additional postoperative cycles after CRS-HIPEC.
• EPIC (early postoperative intraperitoneal chemotherapy) — Repeated postoperative intraperitoneal chemotherapy administrations for 4 to 5 days following CRS-HIPEC, typically using paclitaxel.

Sugarbaker-pioneered protocols pairing CRS-HIPEC with NIPEC or EPIC are associated with high 5-year survival in epithelioid disease at expert centers, though direct randomized comparisons against CRS-HIPEC alone are limited.

Who Qualifies: Patient Selection

CRS-HIPEC is the most demanding cancer operation routinely performed, and patient selection is what separates expert-center outcomes from the average. The 2025 international consensus and the March 2025 India consensus exercise converge on the following framework.

Inclusion Criteria (Strong Indications)

Criterion	Threshold or Requirement
Histology	Epithelioid (strongest indication); selected biphasic considered case-by-case
Performance status	ECOG 0 to 1
Peritoneal Cancer Index (PCI)	≤ 20 preferred; up to 30 in selected ultra-high-volume centers in epithelioid cases
Disease extent	Confined to abdominal cavity; no confirmed extra-abdominal metastases
Organ function	Adequate cardiac, renal, hepatic, and pulmonary reserve to tolerate prolonged anesthesia and major fluid shifts
Resectability	Disease amenable to CC-0 or CC-1 cytoreduction based on preoperative imaging and laparoscopic assessment
Age	No absolute cutoff; age greater than 65 years associated with worse outcomes in some series

Exclusion Criteria (Contraindications)

• Pure sarcomatoid histology — Outcomes are very poor; CRS-HIPEC rarely indicated. Selected biphasic cases with an epithelioid-dominant component may be discussed at multidisciplinary tumor board.
• Very high PCI (greater than 30) — Significantly worse outcomes; may be offered only at ultra-high-volume centers in carefully selected epithelioid cases.
• ECOG performance status of 2 or worse — Associated with high perioperative mortality and poor recovery.
• Extra-abdominal metastases — Distant disease (thoracic, hepatic parenchymal, bone) precludes curative intent.
• Severe cardiopulmonary compromise — Inability to tolerate prolonged anesthesia (6 to 12+ hours) and the major fluid shifts of CRS-HIPEC.
• Active uncontrolled infection or severely compromised immune function.
• Prior extensive abdominal surgeries with dense adhesions that preclude complete cytoreduction (relative contraindication; assessed at diagnostic laparoscopy).

Borderline-Resectable Disease and Neoadjuvant Therapy

Patients with "borderline-resectable" disease — technically feasible but requiring neoadjuvant therapy or complex multivisceral resection — have outcomes intermediate between upfront-resectable and inoperable patients. The 2026 French multicentric experience reported 5-year OS of 84.6 percent in upfront-resectable disease (n=270), 55 percent in borderline-resectable disease, and 12.9 percent in inoperable disease (p<0.0001). Neoadjuvant therapy with platinum/pemetrexed (with or without bevacizumab) is feasible and safe at high-volume centers and may convert borderline-resectable disease into resectable disease in a subset of patients.

The Role of Diagnostic Laparoscopy

Many expert centers now perform diagnostic laparoscopy before committing to full CRS-HIPEC. Laparoscopy allows accurate intraoperative PCI scoring, assessment of mesenteric and small-bowel disease (which can preclude CC-0 cytoreduction even when imaging looks favorable), tissue biopsy for histological confirmation, and identification of patients in whom complete cytoreduction is not achievable — avoiding the morbidity of a futile open laparotomy.

HIPEC Chemotherapy Agents and Protocols

The most commonly used HIPEC agents for peritoneal mesothelioma — based on published evidence and the 2025 international consensus — are summarized below.

Agent	Typical Dose	Duration	Notes
Cisplatin (preferred backbone)	50 to 100 mg/m²	60 to 90 min at 41 to 43 °C	Established platinum cytotoxicity; broad peritoneal distribution
Doxorubicin (with cisplatin)	15 mg/m²	Combined with cisplatin	Synergistic with cisplatin; 2025 consensus preferred combination
Mitomycin C	10 to 16 mg/m²	60 to 90 min	Alternative platinum-free option
Carboplatin	AUC 5	60 to 90 min	Used at some centers; less consensus support

The 2025 international consensus (Brown et al., Annals of Surgical Oncology) achieved strong agreement on cisplatin–doxorubicin as the preferred HIPEC combination for routine peritoneal mesothelioma care. Single-institution series comparing mitomycin C and carboplatin have reported no statistically significant difference in OS or PFS after adjusting for baseline characteristics, though those series have been small.

Staging Tools: PCI and CC Score

Two intraoperative scores anchor every CRS-HIPEC decision.

Peritoneal Cancer Index (PCI)

The PCI is the primary quantitative staging and treatment-planning tool for peritoneal mesothelioma. It divides the abdominal cavity into 13 regions (9 abdominopelvic + 4 small-bowel), each assigned a Lesion Size (LS) score:

• LS 0: no visible disease
• LS 1: lesions less than 0.5 cm
• LS 2: lesions 0.5 to 5.0 cm
• LS 3: lesions greater than 5.0 cm or confluent disease

Maximum composite PCI = 39. Most expert centers use PCI ≤ 20 as the primary surgical-candidacy threshold, with selected ultra-high-volume centers accepting PCI up to 30 in epithelioid disease. PCI greater than 30 is associated with markedly worse survival in most series.

Completeness of Cytoreduction (CC) Score

The CC score is assigned intraoperatively at the end of cytoreduction and is one of the strongest independent predictors of survival.

• CC-0: no visible residual disease (complete cytoreduction)
• CC-1: residual ≤ 2.5 mm (complete; HIPEC-penetrable)
• CC-2: residual 2.5 mm to 2.5 cm (incomplete)
• CC-3: residual greater than 2.5 cm or confluent (incomplete)

CC-0 and CC-1 are both considered "complete cytoreduction" because residual disease at CC-1 is thought to be penetrable by heated intraperitoneal chemotherapy. CC-2 and CC-3 are incomplete and confer substantially worse outcomes; some expert centers will abort the HIPEC phase if CC-2 or CC-3 is reached, on the rationale that HIPEC will not bridge gross residual disease.

There is no widely adopted formal AJCC TNM staging system for peritoneal mesothelioma; PCI plus CC plus histology fill that role in current practice.

What to Expect: Pre-Operative, Intra-Operative, and Recovery

Pre-Operative

Standard pre-CRS-HIPEC workup at expert centers includes:

• Multidisciplinary tumor board review of histology, imaging, and prior treatment
• CT abdomen and pelvis with IV contrast (the accepted first-line modality)
• PET-CT in selected cases to rule out extra-abdominal disease and identify biopsy sites
• MRI in selected cases for detailed peritoneal mapping (an emerging role with some series associating MRI-based planning with improved outcomes)
• Cardiac, renal, hepatic, and pulmonary function evaluation
• Diagnostic laparoscopy with intraoperative PCI scoring at most expert centers before scheduling open CRS-HIPEC
• Nutritional assessment, prehabilitation, and where indicated neoadjuvant chemotherapy

Intra-Operative

CRS-HIPEC is performed under general anesthesia and typically lasts 6 to 12+ hours from skin incision to skin closure. Major fluid shifts are routine; aggressive intraoperative fluid resuscitation, vasoactive support, blood-product administration, and intensive temperature management are standard. The hyperthermia phase requires careful core-temperature monitoring and active cooling to prevent systemic hyperthermia in the patient.

Recovery

Most patients are extubated in the operating room or within 24 hours and are admitted to a surgical ICU for the first 24 to 48 hours. Typical hospital stay is 7 to 14 days at high-volume centers, with longer stays for patients who experience complications. Return to baseline performance status takes 6 to 12 weeks. Short-term postoperative chemotherapy or maintenance chemotherapy decisions are made at follow-up multidisciplinary review.

Complications and Morbidity

CRS-HIPEC is among the highest-morbidity cancer operations performed in modern practice, although outcomes have improved substantially as expert-center volumes have grown. Modern multicenter series report:

• 30-day operative mortality at expert centers: 0 to 2.1 percent
• Major morbidity (Clavien-Dindo grade III or higher): approximately 30 to 51 percent
• Most common complications: anastomotic leak, intra-abdominal abscess, prolonged ileus, pulmonary complications (pleural effusion, pneumonia), renal dysfunction (especially after cisplatin-based HIPEC), hematologic toxicity from systemic absorption of intraperitoneal chemotherapy, and wound complications

The morbidity profile is the central reason CRS-HIPEC is concentrated at high-volume centers — both perioperative mortality and major-morbidity rates correlate inversely with institutional case volume in published series.

Outcomes Anchor (See Mesothelioma_Prognosis for Detail)

This page is the procedural reference; stage-stratified survival data and treatment-pathway comparisons live at Mesothelioma_Prognosis and Peritoneal_Mesothelioma. The single anchor needed in this page is the 2026 French multicentric experience, which is the current benchmark for what an expert-center CRS-HIPEC program achieves in optimally-staged disease:

Resectability Group	n	5-Year OS
Upfront-resectable	270	84.6%
Borderline-resectable	(not separately reported here; see source)	55%
Inoperable	(not separately reported here; see source)	12.9%

The 84.6 percent 5-year OS in upfront-resectable disease is what makes early referral to a high-volume CRS-HIPEC center the most important clinical decision for a newly-diagnosed peritoneal mesothelioma patient. Older anchor figures (59 to 69 percent 5-year OS from earlier-era multicenter analyses) reflect predominantly mixed-resectability cohorts and pre-modern surgical and anesthetic infrastructure; they should not be used as the contemporary benchmark for upfront-resectable, expert-center care.

2025–2026 Consensus Guidelines

Two consensus efforts in 2025 frame current peritoneal mesothelioma care.

• Brown et al., 2025 — International consensus, Annals of Surgical Oncology. Strong agreement endorsed CRS-HIPEC as the standard of care for resectable peritoneal mesothelioma; cisplatin–doxorubicin as the preferred HIPEC combination; epithelioid histology as the strongest surgical indication; and high-volume center referral as a quality-of-care priority.
• March 2025 India consensus exercise. The Indian Network for Development of Peritoneal Surface Oncology / Indian Society of Peritoneal Surface Malignancies reported 100 percent panelist agreement that CRS-HIPEC should be the standard of care for newly diagnosed peritoneal mesothelioma if the disease is completely resectable and there is no contraindication to surgery.

The 2026 French multicentric experience (Noiret et al., European Journal of Surgical Oncology) is the highest-evidence cohort published since the consensus exercises and provides the contemporary outcome benchmark cited throughout this page.

Institutional Volume and Center Selection

Where CRS-HIPEC is performed matters as much as whether it is performed. Across published series, both perioperative mortality and major-morbidity rates correlate inversely with institutional case volume, and 5-year survival correlates positively with center experience. For a newly-diagnosed peritoneal mesothelioma patient, the questions to ask of any prospective CRS-HIPEC program include:

• What is the institution's annual peritoneal mesothelioma CRS-HIPEC case volume?
• What is the surgical team's median operative time and 30-day mortality?
• Does the program perform routine diagnostic laparoscopy before committing to open CRS-HIPEC?
• What HIPEC agents are used as the institutional standard, and does that align with the 2025 consensus (cisplatin–doxorubicin)?
• Is the program affiliated with a comprehensive peritoneal-surface-oncology multidisciplinary clinic?

Mesothelioma_Specialists documents specific U.S. centers performing high-volume CRS-HIPEC for peritoneal mesothelioma.

Timing of Referral

Time-to-CRS-HIPEC matters. Delayed CRS-HIPEC (greater than 12 weeks from diagnostic confirmation) has been associated with reduced life expectancy compared to timely surgery in single-institution series. The clinical implication is straightforward: a newly-diagnosed peritoneal mesothelioma patient should be referred to a high-volume CRS-HIPEC center for evaluation as soon as the diagnosis is confirmed, without waiting for prolonged systemic-chemotherapy trials at non-specialist centers. Centers performing CRS-HIPEC at scale typically offer expedited evaluation pathways for newly-diagnosed referrals.

Frequently Asked Questions

What does HIPEC stand for?

HIPEC stands for hyperthermic intraperitoneal chemotherapy — chemotherapy delivered into the abdominal cavity, heated to 41 to 43 °C, and circulated for 60 to 90 minutes. It is almost always performed as the second phase of CRS-HIPEC, in which surgeons first physically remove all visible tumor through cytoreductive surgery and then immediately deliver the heated chemotherapy.

Is HIPEC the same as CRS-HIPEC?

In practice, no. HIPEC is the chemotherapy phase; CRS-HIPEC is the combined surgery-plus-HIPEC procedure that defines the standard of care for resectable peritoneal mesothelioma. When clinicians refer to "HIPEC for peritoneal mesothelioma" they almost always mean CRS-HIPEC.

Who is a candidate for CRS-HIPEC?

The strongest candidates have epithelioid histology, ECOG performance status of 0 or 1, a Peritoneal Cancer Index of 20 or less, no extra-abdominal metastases, and adequate organ-function reserve to tolerate a 6 to 12+ hour operation. Patients with sarcomatoid histology, very high PCI (greater than 30), poor performance status, or extra-abdominal disease are generally not candidates.

Why is the abdominal chemotherapy heated?

Hyperthermia (41 to 43 °C) adds a direct cytotoxic effect at temperatures above 41 °C, potentiates platinum drug activity (cisplatin in particular), impairs DNA repair in tumor cells, and is thought to improve drug penetration into peritoneal tissues. Whether hyperthermia is essential or whether normothermic delivery would suffice has not been formally established by randomized trials; despite that open question, hyperthermic delivery is the current standard.

How long is the surgery, and how long is the hospital stay?

CRS-HIPEC typically takes 6 to 12+ hours from skin incision to skin closure. Most patients are extubated in the operating room or within 24 hours, spend 24 to 48 hours in a surgical ICU, and total hospital stay is typically 7 to 14 days at high-volume centers. Return to baseline activity takes 6 to 12 weeks.

What is the 5-year survival after CRS-HIPEC?

The contemporary benchmark for upfront-resectable, expert-center CRS-HIPEC is the 2026 French multicentric experience: 5-year overall survival of 84.6 percent in the upfront-resectable subgroup (n=270). Outcomes drop substantially in borderline-resectable (about 55 percent 5-year OS) and inoperable (about 12.9 percent 5-year OS) groups. Stage-stratified detail and treatment-pathway comparisons are at Mesothelioma_Prognosis.

Is CRS-HIPEC available everywhere?

No. CRS-HIPEC is concentrated at high-volume centers because both perioperative mortality and major-morbidity rates correlate inversely with institutional case volume. A newly-diagnosed peritoneal mesothelioma patient should be referred to a high-volume center for evaluation, not treated at a community hospital without peritoneal-surface-oncology expertise. See Mesothelioma_Specialists for a list of U.S. high-volume CRS-HIPEC centers.

What is the difference between HIPEC, NIPEC, and EPIC?

HIPEC is single-session intraoperative hyperthermic (41 to 43 °C) intraperitoneal chemotherapy. NIPEC is single-session normothermic intraperitoneal chemotherapy (no hyperthermia), sometimes used as adjuvant cycles after CRS-HIPEC. EPIC is early postoperative intraperitoneal chemotherapy — repeated postoperative administrations for 4 to 5 days following CRS-HIPEC, typically using paclitaxel. Some Sugarbaker-pioneered protocols pair CRS-HIPEC with NIPEC or EPIC to extend the regional chemotherapy window.

Does insurance cover CRS-HIPEC?

CRS-HIPEC for peritoneal mesothelioma is generally covered by Medicare, Medicaid, and major commercial insurers when performed at recognized centers for established indications. Pre-authorization, second-opinion documentation, and center-specific in-network status all matter; patients should ask their high-volume center's financial-counseling team to coordinate insurance approval before surgery is scheduled.

See also

• Peritoneal_Mesothelioma — Disease overview, pathology, and natural history
• Mesothelioma_Prognosis — Stage-stratified survival, treatment-pathway comparisons, biomarker-driven outcomes
• Mesothelioma_Specialists — High-volume U.S. CRS-HIPEC centers
• Mesothelioma Diagnosis — Pathology workup, imaging, and biopsy techniques
• Mesothelioma_Staging — Staging frameworks across mesothelioma subtypes
• Chemotherapy_for_Mesothelioma — Systemic chemotherapy options
• Mesothelioma Clinical Trials — Active CRS-HIPEC, NIPEC, and immunotherapy trials
• Mesothelioma — Top-level disease hub