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6 cycles of TP (Paclitaxel/Carboplatin), 6 cycles of Gem/CDDP (Gemcitabine/Cisplatin) and 1 cycle of
TP (Paclitaxel/Carboplatin). Post-chemotherapy, the patient had partial response and she proceeded with
secondary CRS and HITAC as mentioned in Table 1. In the early postoperative period, the patient did not
develop significant surgical morbidity (Clavien Dindo grade III/IV). Following three cycles of adjuvant
chemotherapy, the patient remains disease-free with the last follow-up on 12-02-2020.

Patient serial number “2” is a 46-year-old female with no known comorbidities nor significant family
history. She initially presented to another institution with symptoms of abdominal pain, constipation, fever
and weight loss. She was diagnosed with Koch’s abdomen and received tuberculosis treatment for 1 year.
However, she had persistent and worsening of symptoms, so a right-sided intercostal drainage tube was
placed for a right pleural effusion. Image-guided pleural biopsy was performed and histopathology was
suggestive of poorly differentiated carcinoma which was immunopositive for CK7+, ER+ and focal CA125+.
The patient then self-referred to our hospital. After thorough work-up, she was planned for weekly TP
neoadjuvant chemotherapy followed by surgical reassessment before proceeding with interval CRS with
HITAC. Details of the surgical procedure were mentioned earlier and are based on pre- and intra-operative
clinical findings. Post-operative histopathology was consistent with FIGO stage IVA. In the early post-
operative period, the patient developed a recurrent right pleural effusion which necessitated another right
intercostal drainage tube. After delayed clinical recovery, six cycles of adjuvant TP and bevacizumab were
administered to the patient. The patient is currently alive with persistent disease at the last follow-up on
13-03-2020 and is still on bevacizumab based chemotherapy.

Patient serial number “3” is a 29-year-old female with no known comorbidities, significant family
history nor past medical or surgical history. She presented with a dry cough and shortness of breath for
10 months. The patient was worked-up and diagnosed with ovarian carcinoma with right sided malignant
pleural effusion (FIGO IVA). Multidisciplinary tumor board discussion advised for TP based neoadjuvant
chemotherapy followed by CRS and intraperitoneal/intrathoracic chemotherapy. Post 3 cycles TP, the
patient underwent interval CRS with HITAC. The procedure details are mentioned in Table 1 and the
postoperative period was uneventful. Final histopathology reported the same FIGO stage disease because
of similar tumor deposits on the pleura. Three cycles of adjuvant TP regimen were administered to the
patient. At the last follow-up on 19-09-2019, the patient was alive and disease-free.

CONCLUSION
CRS with HITAC is a complex and evolving procedure. These are viable treatment options for cases
of ovarian carcinoma with peritoneal carcinomatosis and pleural disease in the post neoadjuvant
chemotherapy setting. Macroscopic disease can be removed with CRS and the remaining microscopic
disease can be dealt with through HITAC to reduce thoracic recurrences. In this study, there were no life-
threatening surgical morbidities. No mortality was recorded till the last follow-up. Following the technique
described in this study, CRS with HITAC can be safely performed and replicated easily without additional
morbidity or need for extra resources for HITAC. However, multicenter studies with larger numbers of
patients and longer follow-up is warranted to establish reproducibility and acceptance of the procedure.

DECLARATIONS
Acknowledgments
We like to acknowledge our head of department Professor (Dr.) S V S Deo, DR BRA-IRCH, AIIMS, New
Delhi for constant support and inspiration. The acknowledgment extends to all faculty and senior residents
of the Department of Surgical Oncology and Department of Onco-anesthesia and Palliative Care for
intraoperative and postoperative patient care.