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Good Doctor·Hyperthermic Intraperitoneal Chemotherapy | Interpretation of the 2026 Edition CACA Guidelines for HIPEC Clinical Application
Since the early 1980s, when American general surgeon John Spratt [Spratt JS, et al. Cancer Res. 1980; 40: 256–260] first reported the successful use of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) to treat peritoneal pseudomyxoma (PMP), CRS plus HIPEC has become the preferred or effective treatment for a variety of primary or secondary (metastatic) peritoneal malignancies. Currently, across 51 countries and regions worldwide, at least 138 expert consensuses or guidelines have been published on the use of CRS plus HIPEC for treating various peritoneal malignancies [Tonello M, et al. Ann Surg Oncol. 2025; 32: 5795–5806].
2026-09-03
Since the early 1980s, when American general surgeon John Spratt [Spratt JS, et al. Cancer Res. 1980; 40: 256–260] first reported cytoreductive surgery (CRS) combined with… Intraperitoneal hyperthermic chemotherapy Since the successful treatment of peritoneal pseudomyxoma (PMP) with hyperthermic intraperitoneal chemotherapy (HIPEC), CRS plus HIPEC has become the preferred or an effective therapeutic approach for a variety of primary or secondary (metastatic) peritoneal malignancies.
Currently, a total of 51 countries and regions worldwide have issued at least 138 expert consensuses or guidelines on CRS plus HIPEC for the treatment of various peritoneal malignancies [Tonello M, et al. Ann Surg Oncol. 2025; 32: 5795–5806].
The earliest international “Consensus on the Clinical Application of HIPEC” was the expert consensus on “CRS plus HIPEC for the Treatment of Peritoneal Metastases from Colorectal Cancer,” published in 2007 by the Society of Surgical Oncology (SSO) [Esquivel J et al. Ann Surg Oncol. 2007; 14(1): 126–133]. In China, the first published “Expert Consensus on the Clinical Application of HIPEC” was authored by Li Yan and colleagues, released in 2015. Cytoreductive surgery “Expert Consensus on Intraperitoneal Hyperthermic Chemotherapy for Tumors on the Peritoneal Surface” [Li Yan et al., Chinese Journal of Oncology. 2015; 42(4): 198–206].
China’s earliest “Clinical Practice Guideline for HIPEC” was published by the Cervical Cancer Professional Committee of the Chinese Anti-Cancer Association, titled “Clinical Practice Guideline for Intraperitoneal Hyperthermic Perfusion in Gynecologic Oncology (2023 Edition)” [Chinese Anti-Cancer Association, Cervical Cancer Professional Committee. Chinese Journal of Practical Gynecology and Obstetrics. 2023; 39(9): 926–934].
In July 2023, the Guidelines Publishing House of the Chinese Anti-Cancer Association published the “Chinese Guidelines for Integrated Diagnosis and Treatment of Tumors (CACA Guidelines) — C-HIPEC Technology” (i.e., the 2023 edition of the CACA Guidelines on C-HIPEC Technology).
Recently, building on the 2023 edition and following a comprehensive collective review by experts from multiple disciplines—including gastrointestinal surgery, oncology, peritoneal tumor surgery, and gynecology—the content has been thoroughly and systematically updated, particularly with respect to C‑HIPEC techniques and platform requirements (including equipment specifications). The latest version, “Chinese Guidelines for Integrated Cancer Care (CACA) — C‑HIPEC Technology (2026 Edition),” has now been released.
Figure: “Chinese Guidelines for Integrated Cancer Care (CACA) – C-HIPEC Technique (2026 Edition)”
Good Doctor·Hyperthermic Perfusion丨Multi-chamber·Minimally Invasive·Metastasis Control·Ascites Treatment
Five Major Updates
1.
HIPEC technically specifies clear requirements for effective temperature and temperature-control accuracy: 43 ± 0.1°C. Although the “2026 Edition of the C-HIPEC Technical Guidelines” does not specify whether this temperature refers to the inlet or outlet temperature, or to the intracavitary temperature, we interpret “43 ± 0.1°C” as the “intracavitary treatment temperature.”
2.
It lists patients at high risk of peritoneal metastasis from colorectal cancer and suggests that such patients are suitable for “radical surgery for colorectal cancer ( CIS ) Postoperative preventive intraperitoneal hyperthermic perfusion chemotherapy (HIPEC)
High-risk factors for peritoneal metastasis in colorectal cancer include: 1) T3/T4 stage; 2) Positive free tumor cells in peritoneal lavage fluid; 3) Tumor perforation or rupture; 4) intestinal obstruction caused by the primary tumor; 5) positive surgical margins; 6) inadequate or incomplete lymph node dissection (fewer than 12 lymph nodes removed); 7) mucinous or signet-ring cell carcinoma; 8) presence of tumor emboli in blood vessels or lymphatics, as well as neural invasion.
3.
Based on the data from the OVHIPEC‑1 trial and its ten-year follow-up, a Phase III clinical study has further established the clinical value of HIPEC when used in combination following interval debulking surgery (IDS) in patients with advanced ovarian cancer.
In 2018, van Driel et al. published the results of a prospective, randomized controlled trial (OVHIPEC‑1) in the New England Journal of Medicine, which for the first time demonstrated the therapeutic value of HIPEC in patients with advanced ovarian cancer: among those with advanced ovarian cancer following neoadjuvant chemotherapy, a single session of HIPEC administered after interval debulking surgery (IDS) extended median progression-free survival and overall survival by 3.5 months and 11.8 months, respectively, without increasing the rate of postoperative complications [van Driel, WJ, et al. NEJM. 2018; 378: 230–240]. In 2023, Lot Aroson S et al. reported findings from the OVHIPEC study, conducted across eight medical centers in the Netherlands and Belgium and followed up for ten years, further confirming that HIPEC confers substantial long-term benefits by significantly reducing the risks of recurrence and mortality. HIPEC treatment prolonged median progression-free survival (mPFS) and median overall survival (mOS) by 3.6 months and 11.6 months, respectively, with statistically significant differences (mPFS: p = 0.0008; mOS: p = 0.011) [Lot Aroson S, et al. Lancet Oncol. 2023; 24(10): 1109–1118]. In 2020, Chinese researchers, through a multicenter retrospective cohort study involving 584 patients with advanced ovarian cancer who underwent primary cytoreductive surgery, reported that HIPEC significantly reduced the risk of death (mOS: 49.8 months vs. 34.0 months; p < 0.001) [Lei Z, et al. JAMA Network Open 2020; 3(8): e2013940].
The aforementioned clinical study results demonstrate that, for patients with unresectable, heavily burdened advanced ovarian cancer, neoadjuvant HIPEC offers greater advantages than conventional intravenous chemotherapy. Currently, the ICS plus HIPEC treatment regimen has become an important approach in the management of ovarian cancer in China and has been incorporated into the recently published “Chinese Expert Consensus on Neoadjuvant Chemotherapy for Advanced Epithelial Ovarian Cancer (2026 Edition)” [Chinese Society of Gynecologic Oncology, et al. Practical Journal of Obstetrics and Gynecology. 2026; 42(2): 114–121].
4.
The epidemiology of hepatobiliary and pancreatic cancers in China provides a clinical basis for performing HIPEC in patients with peritoneal metastases from these malignancies.
The guidelines note that hepatocellular carcinoma (HCC) accounts for 90% of primary liver cancers; approximately 70% of patients experience recurrence within five years after surgery, and about 16% develop peritoneal metastases. Cholangiocarcinoma (CCA), which includes cancers of the gallbladder and biliary epithelium, has peritoneal metastasis accounting for 33%–46% of all tumor spread and represents a major cause of poor prognosis, with a median survival of less than one year in patients who are unresectable or have distant metastases. Pancreatic carcinoma (PAC) is highly malignant and associated with a poor prognosis, with an age‑standardized five‑year survival rate of only 7.2%; even after curative resection, the recurrence rate can be as high as 75%, with peritoneal recurrence accounting for roughly 50% of these cases. These epidemiological data suggest that, among individuals at high risk for peritoneal metastasis from hepatobiliary and pancreatic malignancies, early intervention and the implementation of individualized HIPEC therapy may improve survival and reduce recurrence rates.
5.
It is proposed that “adjunctive sedation and analgesia” can be employed to facilitate HIPEC therapy.
While continuously monitoring vital signs, commonly used sedatives—dexmedetomidine and remimazolam—are recommended; analgesics—dezocine and pentazocine—are also suggested. Oxycodone 1). Dexmedetomidine, at 0.5 µg/kg, is diluted in 100 mL of normal saline and administered as a slow intravenous infusion over 10–20 minutes; remimazolam, diluted to 1 mg/kg, is infused continuously during surgery at a rate of 0.5–1 mg/kg/h. 2). Dezocine 10 mg or pentazocine 30–60 mg is diluted in 100 mL of normal saline and administered by slow intravenous infusion. 3). If sedation and analgesia are inadequate, oxycodone 10 mg may be diluted in normal saline to a concentration of 1 mg/mL and administered as a slow bolus of 3–5 mg; if the response remains suboptimal after 3 minutes, an additional dose of 1–2 mg may be given, with repeated doses until pain is relieved. If 10 mg of oxycodone proves insufficient, other sedative‑analgesic agents should be added under the guidance of the anesthesiologist, or general anesthesia should be considered.
An evaluation of current HIPEC technologies and platform equipment, both domestically and internationally.
The CACA Guidelines explicitly recommend HIPEC techniques that feature precise temperature control, large-volume insufflation, continuous circulation, and constant‑temperature perfusion, underscoring their pivotal role in the integrated diagnosis and treatment of peritoneal malignancies. However, both domestically and internationally, there remain discrepancies and limitations in HIPEC technologies and platforms.
01
There are differences and limitations in HIPEC technical expertise.
Traditional HIPEC techniques suffer from issues such as inconsistent heating and perfusion methods, as well as incomplete filling of the entire body cavity with the perfusate, leading to treatment blind spots that limit both efficacy and broader clinical adoption. Moreover, international consensus indicates that HIPEC protocols remain far from fully standardized; in particular, for peritoneal metastases from colorectal cancer, significant variations exist across studies in terms of drugs, dosages, durations, and administration routes, resulting in substantial uncertainty in outcome assessments [Hubner M, et al. Ann Surg Oncol. 2024; 31: 567–576].
02
HIPEC platform equipment and pipeline configurations also have differences and limitations.
The hardware-related differences that affect treatment outcomes include slow heating rates and imprecise temperature control in certain HIPEC devices, excessive dead space in the tubing leading to inaccurate drug dosing and variable therapeutic efficacy, and design flaws in the circulation circuitry that result in poor flow or tube blockages.
03
Functional Differences of HIPEC Platform Equipment
Including selectable perfusion modes, clinical application scenarios, and intracavitary temperature visualization, among others.
Clinical Significance of Various Perfusion Modes Before initiating the “circulating perfusion” mode, the HIPEC device first employs a “unidirectional perfusion and irrigation” protocol to thoroughly cleanse and replace postoperative bloody effusions or malignant pleural and peritoneal fluid. This not only reshapes the tumor microenvironment (TME) within the body cavity but also flushes out heat‑induced coagulated proteins, fibrin, as well as free cancer cells and tumor emboli. Consequently, chemotherapeutic agents can reach tumor lesions on the peritoneal surface directly, while simultaneously helping to prevent potential catheter blockages that might arise during subsequent circulating perfusion.
Clinical Application Advantages Across Multiple Departments The clinical application scenarios of body‑cavity hyperthermic perfusion (HIPEC) devices are determined by factors such as the device’s flow rate and velocity range, its controllable precision, and whether it supports minimally invasive and percutaneous catheterization techniques for establishing circulatory access. Currently, overseas HIPEC systems are primarily used for immediate postoperative HIPEC or HITHOC following surgical cytoreductive surgery (CRS). In contrast, certain domestic HIPEC devices not only enable immediate postoperative HIPEC or HITHOC in the operating room after CIS or CRS but can also be administered at the patient’s bedside in departments such as medical oncology, gastroenterology, and pulmonology, or within a dedicated “hyperthermic perfusion treatment room,” without the need for surgery.
Clinical Significance of Intra‑Cavitary Temperature Visualization : Certain HIPEC devices not only display the inlet and outlet temperatures and their corresponding curves, but also feature a “real-time visualization of intracavitary temperature,” effectively making the intracavitary temperature visible. The advantage of this “intracavitary temperature visualization” is that it transforms what was previously a “black-box” approach—relying solely on a few thermocouple readings or inlet/outlet temperatures—into a visual management system that allows for intuitive assessment of the target region’s temperature distribution and uniformity. This ensures more reliable delivery of an effective thermal dose, reduces the risk of treatment failure due to cold zones or hot spots, and minimizes the potential for tissue damage, while also providing quantifiable data to support process optimization and quality control [Lopez-Ramirez, F et al. Eur J Surg Oncol. 2026; 52(1): 110536. Cooney OS, et al. J Gastrointest Oncol. 2024; 15(4): 1847–60].
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