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Appropriate patient selection is of primary importance to successful cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC). Given the high morbidity rate associated with these combined procedures, we need to select patients who will derive maximum benefits from treatment and who carry lower risks of postoperative complications and mortality. The high morbidity and mortality rates, especially in treatment groups approaching this type of surgery for the first time, have raised concern and often criticism [1, 2]. At the same time, besides problems linked to postoperative complications, criteria for selecting patients to undergo integrated treatment must take into account preoperative factors predicting a favorable oncologic outcome. Hence, we need to know which tumors causing peritoneal spread this combined treatments should target and to define the extent of peritoneal spread to use as a cutoff beyond which these procedures are contraindicated. To rationalize this topic, even though schematizing has its limitations, we divided selection criteria according to whether they most directly address patients’ characteristics, the site and histology underlying peritoneal spread, and the extent of peritoneal and extraperitoneal malignant spread.

Diffuse peritoneal malignancy raises major therapeutic problems and puts the patient’s life at high risk. In the past, systemic chemotherapy regimens functioned as a purely palliative approach, and palliative surgery aimed merely at reducing the symptoms, being unable to alter the natural course of the disease [1]. At the beginning of the 1990s, thanks to Sugarbaker’s pioneering efforts, research began to develop integrated procedures for treating peritoneal surface malignancies based on a therapeutic approach. This approach involved cytoreductive surgery (CRS) (peritonectomy procedures) combined with perioperative intraperitoneally administered chemotherapy (IP-CHT)—eventually integrated with hyperthermia—done immediately after surgical cytoreduction ended [hyperthermic intraperitoneal chemotherapy (HIPEC)], or during the early postoperative course [early postoperative intraperitoneal chemotherapy (EPIC)] [2]. The therapeutic rationale underlying integrated treatment originates from advances in systemic chemotherapy and improved knowledge about the pharmacological mechanisms underlying endoperitoneal drug delivery. The rationale for cancer chemotherapy hinges upon several well-known theoretical hypotheses. According to the Gompertzian cellular kinetic model (the tumor-growth profile can be depicted as an S-shaped curve), a tumor initially grows slowly and then rapidly becomes fast growing [3]. As the tumor enlarges, its blood supply and growth slows down, and a larger tumor cell percentage gradually enters a nonproliferative cell-cycle stage (Fig. 8.1).

Pretreatment and preoperative assessment of peritoneal carcinomatosis (PC) can be very challenging in the field of imaging, and a comprehensive study could require integration of multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) with conventional and diffusion-weighted sequences, and positron emission tomography (PET) or PET/CT [1, 2]. These imaging tools are able to provide accurate information on morphology, size, and location of peritoneal implants, lymph node enlargement, and presence of ascites. A detailed preoperative assessment of PC is essential to provide the surgeon with a detailed preoperative map of carcinomatosis and allow evaluation of the radiological Peritoneal Cancer Index (PCI) [3, 4]. This score correlates with patient prognosis, and the ability to calculate it using CT and MR with diffusion-weighted imaging (DWI) before any treatment is begun can guide therapeutic management of the patient. It can differentiate patients who are candidates for surgical intervention with hyperthermic intraperitoneal chemotherapy (HIPEC) from those with a high radiological PCI and who are therefore candidates for systemic chemotherapy [5]. The principal diagnostic techniques for accurate evaluation of peritoneal malignancy are represented by MDCT, MRI, PET, and combined PET/MDCT or PET/MRI. The role of ultrasound (US) imaging is limited in peritoneal imaging. However, this imaging modality is often the first one used when peritoneal disease is discovered incidentally, and it remains one of the diagnostic techniques for image-guided biopsy to obtain a histological diagnosis [1].

Until recent years a diagnosis of peritoneal carcinomatosis (PC) from intra-abdominal solid tumors carried a uniformly fatal prognosis, often within weeks or months. Since the 1980s, following the intuition of an American surgeon, Paul Sugarbaker, combined treatment modalities of PC have developed considerably. Since the first pioneering approaches on the treatment of “pseudomyxoma peritonei”