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are outlined along with accompanying intra-operative images. Patient demographics, clinical and follow-up
details were also described briefly. No comparative analysis with control patients was done. Adjustments in
chemotherapy dose are not mandatory for HITAC. Of three patients, one had intrathoracic recurrence on follow-
up; no mortality was recorded HITAC is a complex and potentially harmful procedure whose toxicity profile is still
poorly known. Morbidity was not life-threatening and survival was acceptable.

Keywords: Hyperthermic intraperitoneal chemotherapy, hyperthermic intrathoracic chemotherapy, ovarian
carcinoma, cytoreduction surgery, peritoneal carcinoma index

INTRODUCTION
Previously, peritoneal disease was considered terminal and systemic chemotherapy was offered for
palliative intent while palliative surgery only had a role in symptom relief. With the advent of cytoreductive
surgery (CRS) in the early 1990’s, it is now the accepted treatment modality for a subset of patients with
peritoneal carcinomatosis from pseudomyxoma peritonei, appendiceal adenocarcinoma and mesothelioma,
[1]
and has also showed promising results in selected patients with ovarian, colorectal and gastric cancer . The
purpose of CRS is to resect all macroscopic disease through peritonectomy and involved viscera followed
by intraperitoneal chemotherapy by targeting residual microscopic disease through provision of a high
[2]
intraperitoneal concentration with lower systemic toxicity . If CRS is complete, the more provocative
[2,3]
procedure hyperthermic intraperitoneal chemotherapy (HIPEC) is performed in the same setting .
[4]
HIPEC improves both quality of life and survival . These treatments are based on the concept that when
disease is limited to the peritoneal cavity, it is still considered locoregional. The comprehensive CRS
[3]
approach was described by Dr. Sugarbaker in 2007. Evidence for hyperthermia is based on accelerated
[5]
cell death at 41-43 °C in experimental settings . The additive toxic effects of HIPEC have also been
[6]
documented in the literature . Interval CRS and HIPEC resulted in longer recurrence-free and overall
survival among FIGO stage III epithelial ovarian cancer than surgery alone, and did not result in excessive
[7]
side effects . It also offers a significant survival benefit to patients with recurrent epithelial ovarian cancer,
[8]
especially in patients with complete CRS . There is no randomized controlled study or feasibility study
demonstrating the efficacy of hyperthermic thoracoabdominal chemotherapy (HITAC) over HIPEC
[9]
however. Erasmus et al. reported that chemotherapeutic drugs were also absorbed from the pleural
cavity like the peritoneal cavity. In the case of HITAC, the intrapleural concentration of chemotherapeutic
drugs was persistently high compared to plasma. The current study is focused on the technical aspects and
feasibility of HIPEC and HITAC in ovarian cancer patients. It does compare HIPEC alone with HIPEC and
HITAC. Cognizant of the beneficial effects of HIPEC in selected patients with ovarian cancer, the same
strategy was applied through HITAC in patients with thoracic involvement. This is the first study of its
kind in the Indian patient population.

MATERIALS AND METHODS
This is a retrospective study of three prospectively selected patients with ovarian carcinoma and metastatic
pleural effusion treated with CRS and HITAC after neoadjuvant chemotherapy. The aim was to describe
the technical aspects of the surgery with brief descriptions of the postoperative outcomes and treatment-
related morbidities on follow up.

CRS technical aspects
For CRS, a midline laparotomy extending from the xiphoid process to symphysis pubis was performed to
provide greater exposure of the abdomen. Bilateral pelvic and retroperitoneal lymph node dissection with
total omentectomy were done routinely as a part of CRS in ovarian cancer apart from total hysterectomy
and salpingo-oophorectomy. Regarding peritonectomy, we do not routinely practice total peritonectomy