Cytoreductive Surgery

Cytoreductive Surgery for Peritoneal Mesothelioma

Cytoreductive surgery (CRS) is a major operation used to remove as much visible peritoneal mesothelioma as safely possible from the abdomen. It is also called surgical cytoreduction or debulking surgery.

For eligible patients, doctors often combine cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). CRS removes visible tumors, while HIPEC is intended to treat microscopic cancer cells that may remain after surgery.

CRS with HIPEC may help control peritoneal mesothelioma, relieve symptoms, and extend survival for carefully selected patients. However, the treatment is complex and is not appropriate for everyone. Patients should be evaluated by a multidisciplinary team experienced in treating peritoneal mesothelioma.

What Is Cytoreductive Surgery?

Cytoreductive surgery is a cancer treatment that reduces the amount of tumor in the body. During cytoreduction surgery for peritoneal mesothelioma, the surgeon removes visible tumors from the peritoneum, which is the thin membrane lining the abdominal cavity and covering many abdominal organs.

The goal is to remove all visible cancer when this can be done safely. Surgeons may also need to remove portions of the peritoneum and other tissues or organs affected by the cancer.

Although surgery can remove tumors that the surgeon can see, it cannot guarantee that every cancer cell has been eliminated. Microscopic cells may remain and cause the cancer to return. This is one reason doctors may recommend additional treatment after surgical cytoreduction.

Cytoreductive Surgery Quick Facts

• CRS removes as much visible cancer as safely possible.
• The operation may take several hours.
• Some patients need portions of affected tissues or organs removed.
• CRS is often followed by HIPEC for eligible patients.
• A hospital stay commonly lasts approximately one to two weeks.
• Broader recovery may take several weeks or months.
• Eligibility depends on the patient’s health, tumor characteristics, and extent of disease.

Cytoreductive Surgery vs. Debulking Surgery

The terms cytoreductive surgery and debulking surgery are often used interchangeably. Both describe surgery performed to reduce the amount of cancer in the body.

However, some specialists use the terms differently. Complete cytoreduction generally refers to removing all visible disease. Debulking may refer to removing only part of the cancer when complete removal is not possible or safe.

For patients with peritoneal mesothelioma, the amount of cancer left after surgery can affect treatment planning and prognosis. Patients can ask their surgeon whether the goal is complete cytoreduction or partial, symptom-relieving debulking.

Who Is Eligible for Cytoreductive Surgery?

Cytoreductive surgery is generally considered for patients whose peritoneal mesothelioma may be removed surgically and who are healthy enough to tolerate an extensive operation.

When deciding whether someone is a candidate, doctors may consider:

• The location and extent of cancer in the abdomen
• Whether the cancer has spread outside the abdominal cavity
• Whether surgeons expect to remove all or nearly all visible disease
• The patient’s age and overall health
• The patient’s ability to complete everyday activities
• Heart, lung, liver, kidney, and bone marrow function
• Mesothelioma cell type and other tumor characteristics
• Previous surgeries and cancer treatments
• The potential benefits compared with the risks

Doctors may use imaging scans, blood tests, and sometimes laparoscopy to assess the cancer. A laparoscopy uses a small camera inserted through an incision in the abdomen to help doctors examine the disease.

The medical team may also calculate a Peritoneal Cancer Index (PCI). This score helps describe how extensively cancer has spread throughout different areas of the abdomen. There is no single PCI cutoff that applies to every patient or treatment center.

Patients with the epithelioid cell type, cancer largely confined to the abdomen, and a good overall health status may be more likely to qualify. Eligibility standards can vary, so a second opinion from an experienced peritoneal mesothelioma specialist may be helpful.

Preparing for Cytoreductive Surgery

Before surgery, the treatment team will explain how to prepare and what to expect. Preoperative testing may include:

• CT scans or other imaging
• Blood and urine tests
• Heart and lung testing
• A nutritional assessment
• A medication review
• An anesthesia evaluation

Some patients may need to stop or adjust certain medications before surgery. Patients should not stop taking prescription medication unless their healthcare team tells them to do so.

Depending on the planned operation and the treatment center’s practices, patients may also receive instructions about eating, drinking, or completing a bowel preparation. Bowel preparation is not required for every patient.

Because recovery can take time, patients should arrange for transportation and help at home after discharge. Driving, lifting, work, household responsibilities, and other activities may be limited.

What Happens During Cytoreduction Surgery?

The exact surgical cytoreduction procedure depends on where the cancer is located and how extensively it has spread. CRS is performed under general anesthesia and may take several hours.

The procedure generally involves the following steps:

1. The surgeon opens and examines the abdomen. The surgical team determines where the cancer is located and whether it can be removed safely.
2. Visible tumors are removed. The surgeon removes cancer from the peritoneum and other affected areas.
3. Affected tissue may be removed. Depending on the tumor’s location, the surgeon may perform one or more peritonectomy procedures to remove portions of the abdominal lining.
4. Involved organs may be treated or removed. Surgery may include an omentectomy, bowel resection, splenectomy, or removal of other involved tissue. Not every patient needs an organ or section of the bowel removed.
5. The surgeon assesses the remaining cancer. A completeness of cytoreduction score may be used to describe how much visible disease remains after surgery.
6. Additional treatment may be administered. If HIPEC is part of the treatment plan, it is usually delivered before the operation is completed.
7. The abdomen is reconstructed and closed. The surgeon reconnects or repairs tissues as needed and closes the incision.

The extent of CRS varies substantially among patients. In some cases, the surgical team may discover that complete cytoreduction is not possible without causing unacceptable harm. The surgeon may then remove only part of the cancer or adjust the treatment plan.

Tissues and Organs That May Be Treated

Peritoneal mesothelioma can grow across the abdominal lining and affect nearby tissues or organs. Depending on the location of the cancer, cytoreductive surgery may involve:

• The peritoneum
• The omentum
• Portions of the small or large intestine
• The spleen
• The gallbladder
• Parts of the stomach
• The diaphragm’s abdominal lining
• Reproductive organs
• Other affected abdominal or pelvic tissues

An omentectomy, or removal of the omentum, is commonly included because peritoneal cancers can spread to this apron-like layer of fatty tissue covering the abdominal organs.

This does not mean every patient will need these tissues or organs removed. The surgeon will explain what may be necessary based on imaging, examination, and findings during the operation.

How HIPEC May Be Combined with Cytoreductive Surgery

Cytoreductive surgery is often followed by hyperthermic intraperitoneal chemotherapy for eligible patients with peritoneal mesothelioma. The treatments serve different purposes: CRS removes visible tumors, while HIPEC targets microscopic cancer cells remaining in the abdominal cavity.

Not every patient receives HIPEC. A specialist will consider the extent of the cancer, the patient’s overall health, and whether surgeons believe they can achieve complete or near-complete cytoreduction.

Learn more about how HIPEC chemotherapy works, including how the treatment is administered and its possible benefits and side effects.

Recovery After Cytoreductive Surgery

Each patient’s recovery depends on the extent of surgery, the tissues or organs treated, the development of complications, and the patient’s overall health.

Recovery in the Hospital

Patients commonly remain in the hospital for approximately seven to 14 days, although some hospital stays are shorter or longer.

During this time, the healthcare team may monitor:

• Pain and incision healing
• Heart rate, blood pressure, temperature, and oxygen levels
• Kidney function and blood counts
• Return of bowel function
• Eating and nutrition
• Walking and physical activity
• Signs of infection, bleeding, or blood clots

Patients may temporarily need oxygen, surgical drains, a feeding tube, intravenous nutrition, or other support. These measures are not required for every patient.

Walking and other light activities may begin in the hospital. Movement can support recovery and help reduce the risk of complications such as blood clots and pneumonia.

Recovery at Home

Patients may feel weak, tired, or uncomfortable for several weeks after leaving the hospital. Eating patterns and bowel function may also take time to return to normal.

Activity should be increased gradually according to the surgical team’s instructions. Patients may need at least six weeks before returning to a wider range of everyday activities. Heavy lifting, strenuous exercise, and physically demanding work may be restricted for longer.

Returning to work can take several weeks or months, depending on the extent of surgery, the patient’s recovery, and the type of work performed. Patients should follow their surgeon’s individual recommendations.

Risks and Complications of CRS

CRS is a major operation with potentially serious risks. Complication rates depend on the extent of surgery, the patient’s health, whether HIPEC is administered, and the treatment center’s experience.

Possible complications include:

• Bleeding
• Infection
• Blood clots
• Pneumonia or other breathing problems
• Delayed return of bowel function
• Bowel obstruction
• Leakage where sections of the bowel were reconnected
• Changes in blood cell counts
• Kidney problems
• Nutritional problems
• Wound-healing problems
• A temporary or permanent ostomy
• Reactions to anesthesia
• Death in rare cases

Patients should ask their surgeon about the risks most relevant to their treatment plan. They may also want to ask about the center’s experience, complication rates, and available postoperative support.

What Is the Success Rate of Cytoreductive Surgery?

There is no single success rate for cytoreductive surgery. Success can have different meanings, including:

• Removing all visible cancer
• Reducing symptoms
• Improving quality of life
• Delaying recurrence
• Extending survival

Results depend on the amount and location of disease, mesothelioma cell type, lymph node or distant spread, the patient’s health, and how much cancer the surgeon can remove.

A meta-analysis of 20 observational studies involving 1,047 patients with malignant peritoneal mesothelioma reported estimated survival rates of 84% at one year, 59% at three years, and 42% at five years after CRS with HIPEC. However, the studies used different treatment approaches and included carefully selected patients. These statistics cannot predict an individual patient’s outcome.

Current expert guidance supports CRS followed by HIPEC for eligible patients with diffuse malignant peritoneal mesothelioma. However, much of the evidence comes from observational studies rather than randomized clinical trials, and treatment practices vary among medical centers.

Can Cytoreductive Surgery Cure Peritoneal Mesothelioma?

Cytoreductive surgery is not considered a guaranteed cure for peritoneal mesothelioma. Even when the surgeon removes all visible tumors, microscopic cancer cells may remain.

Some carefully selected patients experience long periods without signs of cancer following CRS and additional treatment. However, the cancer may return, and patients generally need continued imaging, follow-up appointments, and monitoring.

A mesothelioma specialist can explain the goals of surgery and how an individual patient’s disease characteristics may affect the expected outcome.

Questions to Ask a Mesothelioma Surgeon

Patients considering cytoreductive surgery may want to ask:

• Am I a candidate for complete cytoreduction?
• What is the goal of surgery in my case?
• How many CRS procedures has this center performed?
• How often does your team treat peritoneal mesothelioma?
• Which tissues or organs might need to be removed?
• How likely is complete cytoreduction?
• Will HIPEC be part of my treatment plan?
• What complications are most common at this center?
• How long should I expect to remain in the hospital?
• When might I return to driving, work, and normal activities?
• What help will I need after leaving the hospital?
• What other treatments might I need?
• What are my options if complete cytoreduction is not possible?

Finding a Peritoneal Mesothelioma Specialist

Cytoreductive surgery requires an experienced surgical and oncology team. A peritoneal mesothelioma specialist can review a patient’s diagnosis, overall health, previous treatment, and extent of disease to determine whether surgery may be appropriate.

Patients may benefit from seeking a second opinion at a high-volume cancer center, especially if they were initially told surgery was not an option. A second opinion does not guarantee eligibility, but it can help patients understand their treatment choices.

Our patient advocates can help patients and families learn more about mesothelioma specialists, treatment centers, and questions to ask when seeking a second opinion. Connect with our patient advocates or download our free mesothelioma guide for additional information and support.

Cytoreductive Surgery FAQs

What is cytoreductive surgery?

Cytoreductive surgery is an operation that removes as much visible cancer as safely possible. For peritoneal mesothelioma, surgeons remove tumors from the abdominal lining and may remove other affected tissues or organs.

Is cytoreductive surgery the same as debulking surgery?

The terms are often used interchangeably. However, some doctors use complete cytoreduction to mean removing all visible disease and debulking to describe removing only part of the cancer.

How long does cytoreductive surgery take?

Cytoreductive surgery may take several hours. The exact duration depends on the amount and location of cancer and whether additional procedures or HIPEC are included.

How long does recovery take?

A hospital stay commonly lasts approximately one to two weeks. Recovery at home may take six weeks or longer, while returning to strenuous work or activity can take several months.

What organs may be removed during cytoreductive surgery?

Depending on where the cancer has spread, surgeons may remove the omentum, spleen, gallbladder, reproductive organs, or sections of the bowel, stomach, peritoneum, or other affected tissue. Not every patient needs an organ removed.

How much does cytoreductive surgery cost?

There is no standard cost for treatment like CRS. Expenses depend on insurance coverage, the treatment center, the extent of surgery, hospital stay, anesthesia, complications, and whether other treatments are administered. Patients can ask the hospital’s financial counselor and their insurance provider for an individualized estimate.

Can peritoneal mesothelioma return after surgery?

Yes. Peritoneal mesothelioma can return even when surgeons remove all visible cancer. Patients need continued follow-up appointments and imaging so their medical team can watch for signs of recurrence.