PIPAC Treatment: Pressurized Intraperitoneal Aerosol Chemotherapy Guide

Pressurized intraperitoneal aerosol chemotherapy, commonly known as PIPAC, represents an innovative approach to treating cancer that has spread to the peritoneum—the membrane lining the abdominal cavity. This advanced therapeutic technique delivers chemotherapy medication as a fine, pressurized mist directly into the abdomen, offering new hope for patients with limited treatment options. While still considered experimental in many settings, PIPAC has shown promising results in managing advanced peritoneal cancers and improving quality of life for patients facing challenging diagnoses.

Understanding PIPAC: How This Treatment Works

PIPAC is a specialized cancer treatment that introduces chemotherapy medication into the abdominal cavity in the form of an aerosolized mist. Unlike traditional chemotherapy that circulates throughout the entire body or liquid chemotherapy washed through the abdomen, PIPAC uses pressurization to enhance the penetration and distribution of cancer-fighting medication directly where it’s needed most.

The procedure involves a minimally invasive laparoscopic surgery during which healthcare providers create small incisions in the abdomen. Through these tiny openings, they insert a camera and specialized equipment designed to convert liquid chemotherapy into a fine aerosol. The abdomen is then carefully inflated with carbon dioxide gas, creating a pressurized environment that helps the medication distribute evenly throughout the abdominal cavity and penetrate deeper into tumor tissue.

This pressurized delivery system is what sets PIPAC apart from other intraperitoneal chemotherapy methods. The combination of aerosolization and pressure allows the medication to reach areas that might be difficult to treat with conventional approaches, including small tumor deposits and hard-to-access regions within the abdominal cavity.

Which Cancers Can Be Treated with PIPAC?

PIPAC is primarily utilized for treating peritoneal metastases—cancers that originated in other organs but have spread to the peritoneum. The treatment has been studied and applied most extensively for several types of cancer:

Colorectal Cancer: When colon or rectal cancer spreads to the peritoneal lining, PIPAC may be considered as part of a comprehensive treatment strategy, particularly when the disease has not responded adequately to standard systemic chemotherapy.

Gastric Cancer: Stomach cancer with peritoneal involvement has been one of the focus areas for PIPAC research, with studies examining how this treatment can help manage disease progression and symptoms.

Appendiceal Cancer: Cancer originating in the appendix that spreads to the peritoneum may benefit from PIPAC treatment, especially in cases where traditional surgical approaches are not feasible.

Ovarian Cancer: Women with ovarian cancer that has spread throughout the abdominal cavity may be candidates for PIPAC, particularly when other treatment options have been exhausted or proven ineffective.

Peritoneal Mesothelioma: This rare cancer affecting the peritoneal lining may also be treated with PIPAC in select cases, though research in this area is ongoing.

The PIPAC Procedure: What to Expect

Understanding the PIPAC procedure can help patients feel more prepared and reduce anxiety about the treatment process. Here’s a step-by-step overview of what typically happens:

Before the Procedure

Patients undergo thorough evaluation including imaging studies, blood work, and assessment of overall health status. Your medical team will review your medical history, current medications, and discuss potential risks and benefits. Most patients are advised to avoid eating or drinking for several hours before the procedure.

During the Procedure

PIPAC is performed under general anesthesia, meaning you’ll be completely asleep and pain-free throughout the procedure. The surgeon makes two or three small incisions, typically less than one centimeter each, in the abdominal wall. A laparoscopic camera is inserted to visualize the abdominal cavity, and specialized instruments are introduced to deliver the treatment.

The abdomen is inflated with carbon dioxide gas to create working space and build pressure within the cavity. The chemotherapy medication is then aerosolized and sprayed into the abdomen using a high-pressure nebulizer system. The pressurized mist circulates throughout the abdominal cavity for approximately 30 minutes, allowing the medication to contact tumor surfaces and penetrate into cancer tissue.

After the dwell time is complete, the chemotherapy aerosol and carbon dioxide gas are safely evacuated through a closed filtration system designed to protect healthcare workers from exposure. The small incisions are then closed with sutures or surgical glue. The entire procedure typically takes 60 to 90 minutes.

After the Procedure

Most patients are monitored in a recovery area for several hours following PIPAC. Many people can go home the same day, though some may require an overnight hospital stay depending on their individual circumstances and overall health status. Recovery is generally faster than with traditional open abdominal surgery due to the minimally invasive nature of the procedure.

PIPAC Treatment Schedule and Duration

PIPAC is typically administered as a repeated treatment rather than a one-time procedure. The standard treatment interval is approximately every six to eight weeks, allowing time for recovery between sessions and for assessment of treatment response.

The total number of PIPAC treatments varies based on individual response, disease characteristics, and treatment goals. Some patients may receive three to six cycles, while others may continue treatment for longer periods if they’re experiencing benefit without significant side effects. Throughout the treatment course, patients usually continue receiving systemic chemotherapy as well, creating a comprehensive approach that targets cancer both locally in the abdomen and throughout the body.

Regular monitoring through imaging studies, tumor marker blood tests, and clinical assessment helps your healthcare team evaluate how well the treatment is working and determine whether continuing PIPAC remains appropriate.

Benefits and Goals of PIPAC Treatment

PIPAC offers several potential advantages for patients with peritoneal cancer spread:

Disease Control: In many cases, PIPAC can help slow or stabilize cancer progression, buying valuable time and potentially extending survival. Studies have shown disease control rates ranging from 50% to 75% in select patient populations.

Symptom Management: For patients experiencing troublesome symptoms related to peritoneal cancer, particularly ascites (fluid accumulation in the abdomen), PIPAC can provide meaningful relief. Reducing tumor burden in the abdominal cavity may decrease fluid production and improve comfort.

Bridging to Surgery: Some patients initially considered unsuitable for cytoreductive surgery may experience sufficient tumor shrinkage with PIPAC to make surgical removal feasible. Research indicates that approximately 10% to 15% of patients who receive PIPAC may later become candidates for potentially curative surgery.

Quality of Life Improvement: Multiple studies have reported that patients receiving PIPAC often experience better quality of life compared to those treated with systemic chemotherapy alone. The minimally invasive nature of the procedure, combined with its effectiveness in controlling disease, contributes to improved well-being.

Lower Systemic Toxicity: Because PIPAC delivers chemotherapy directly to the tumor site at much lower doses than whole-body chemotherapy, it typically causes fewer systemic side effects. This can mean less nausea, fatigue, and other chemotherapy-related symptoms.

Reduced Hospitalization: The outpatient or short-stay nature of PIPAC means patients spend less time in the hospital and more time at home with loved ones compared to more invasive surgical approaches or prolonged chemotherapy hospitalization.

Side Effects and Safety Considerations

While PIPAC is generally well-tolerated compared to high-dose systemic chemotherapy, it’s important to understand potential side effects and risks associated with the treatment.

Common Side Effects

Most side effects are mild and temporary, resolving within a few days to a week after each treatment session:

• Abdominal discomfort: Pain, cramping, or a feeling of fullness in the abdomen is common after PIPAC. This typically results from the gas used to inflate the abdomen and generally improves within 24-48 hours.
• Shoulder or chest pain: Residual gas can irritate the diaphragm, causing referred pain to the shoulders or chest. This is temporary and resolves as the gas is absorbed by the body.
• Nausea and vomiting: Some patients experience digestive upset following the procedure, though anti-nausea medications can effectively manage these symptoms.
• Fatigue: Feeling tired or lacking energy for a few days after treatment is normal as your body recovers from both the procedure and the chemotherapy exposure.
• Bloating and gas: Abdominal distention and gas may persist for several days as residual carbon dioxide is eliminated.
• Changes in bowel habits: Temporary constipation or diarrhea may occur but typically normalizes within a week.
• Decreased appetite: Some patients notice reduced interest in food for a few days following treatment.

Less Common but Serious Risks

While rare, more serious complications can occur:

• Infection: Any surgical procedure carries infection risk, though the minimally invasive nature of PIPAC makes this uncommon. Signs of infection include fever, increasing abdominal pain, or redness around incision sites.
• Bleeding: Injury to blood vessels during the procedure can cause internal bleeding, though this is rare with experienced surgeons.
• Organ injury: Damage to intestines or other abdominal organs is possible but uncommon. Multiple previous surgeries can increase this risk due to scar tissue.
• Adhesion formation: Scar tissue may develop inside the abdomen after repeated procedures, potentially causing bowel obstruction in some cases.
• Port site metastases: In rare instances, cancer cells may implant at the sites where instruments were inserted, though this appears less common with PIPAC than with some other procedures.

Your healthcare team will carefully monitor you for any complications and provide detailed instructions about warning signs that should prompt immediate medical attention.

Effectiveness and Success Rates of PIPAC

The effectiveness of PIPAC varies depending on cancer type, extent of disease, prior treatments, and individual patient factors. Research continues to define which patients are most likely to benefit from this innovative treatment approach.

Disease Control and Response

Studies examining PIPAC outcomes have reported encouraging results:

• Disease stabilization or improvement occurs in approximately 50% to 75% of patients with colorectal or ovarian cancer with peritoneal metastases.
• Some patients experience actual tumor shrinkage, while others achieve disease stabilization where cancer stops growing or spreading.
• Response tends to be better in patients with limited peritoneal disease burden compared to those with extensive tumor involvement.
• Patients who complete multiple PIPAC cycles generally show better outcomes than those who receive only one or two treatments.

Survival Outcomes

While PIPAC is primarily considered a palliative treatment, emerging evidence suggests it may extend survival in certain patient populations:

• Some studies have shown improved overall survival in patients receiving PIPAC plus systemic chemotherapy compared to systemic chemotherapy alone.
• Median survival varies widely depending on cancer type and disease extent, ranging from several months to over two years in some series.
• Patients who achieve disease control or response with PIPAC typically have longer survival than those whose disease progresses despite treatment.

Quality of Life Benefits

Beyond survival metrics, PIPAC has demonstrated meaningful impacts on patient well-being:

• Most patients report stable or improved quality of life during PIPAC treatment.
• Control of ascites and abdominal symptoms provides significant comfort benefits.
• The ability to maintain treatment in an outpatient setting allows patients to spend more time at home and maintain daily activities.
• Fewer hospitalizations for complications or symptom management are reported in patients receiving PIPAC.

It’s important to note that PIPAC is still being studied, and long-term outcome data continues to accumulate. Individual results vary considerably, and your healthcare team can provide more specific information based on your particular situation.

PIPAC Compared to Other Treatments

PIPAC vs. HIPEC (Hyperthermic Intraperitoneal Chemotherapy)

Both PIPAC and HIPEC deliver chemotherapy directly into the abdominal cavity, but they differ significantly in approach and application:

Procedure Type: HIPEC is performed during major open surgery, typically following cytoreductive surgery where visible tumors are removed. PIPAC is a minimally invasive laparoscopic procedure that doesn’t involve tumor removal.

Treatment Delivery: HIPEC uses heated liquid chemotherapy that bathes the abdominal cavity for 60-90 minutes during open surgery. PIPAC delivers pressurized chemotherapy aerosol during a minimally invasive procedure.

Treatment Intent: HIPEC combined with cytoreductive surgery aims for potential cure in select patients with limited peritoneal disease. PIPAC is generally palliative, focusing on disease control and symptom management.

Recovery: HIPEC with cytoreductive surgery requires extensive recovery, often including weeks of hospitalization and months of recuperation. PIPAC recovery typically takes days to a week with minimal hospitalization.

Repeatability: HIPEC is usually a one-time treatment. PIPAC can be repeated multiple times at regular intervals.

Patient Selection: HIPEC candidates must be healthy enough to withstand major surgery and have limited peritoneal disease. PIPAC can be offered to patients not suitable for major surgery or those with more extensive disease.

PIPAC vs. Systemic Chemotherapy Alone

Compared to systemic chemotherapy delivered intravenously or orally:

• PIPAC delivers higher concentrations of medication directly to tumor sites in the abdomen while using lower overall doses.
• Side effects from PIPAC tend to be more localized and less severe than those from full-dose systemic chemotherapy.
• PIPAC is used in addition to, not instead of, systemic chemotherapy in most treatment protocols.
• The combination approach targets cancer both locally in the abdomen and throughout the body.

Who Is a Candidate for PIPAC?

Determining whether PIPAC is appropriate involves careful evaluation by a multidisciplinary team familiar with this specialized treatment. General candidacy criteria include:

Cancer-Related Factors

• Confirmed peritoneal metastases from colorectal, gastric, appendiceal, ovarian, or other abdominal cancers
• Disease that has progressed on or is not suitable for standard treatments
• Peritoneal disease that cannot be completely removed surgically
• Absence of or limited cancer spread outside the abdominal cavity

Patient Health Factors

• Overall health status adequate to undergo repeated minimally invasive procedures
• Adequate organ function, particularly kidney and liver function
• Ability to tolerate general anesthesia
• Expected survival of at least several months to benefit from multiple treatment cycles
• Performance status sufficient to recover between treatments

Situations Where PIPAC May Not Be Appropriate

PIPAC may not be suitable for patients with:

• Extensive scar tissue (adhesions) from multiple previous surgeries making safe access to the abdomen difficult
• Complete bowel obstruction preventing safe inflation of the abdomen
• Very poor overall health status or limited life expectancy
• Extensive cancer spread outside the abdominal cavity
• Severe organ dysfunction that would make treatment unsafe

Your healthcare team will conduct thorough evaluation including imaging studies, blood tests, and assessment of your overall condition to determine whether PIPAC represents a good treatment option for your specific situation.

PIPAC and Cytoreductive Surgery: Understanding the Relationship

Cytoreductive surgery (CRS), also called debulking surgery, involves surgical removal of all visible cancer tissue from the peritoneum and affected abdominal organs. The relationship between PIPAC and cytoreductive surgery can take several forms:

PIPAC After Cytoreductive Surgery

Patients who have previously undergone cytoreductive surgery may later develop cancer recurrence in the peritoneum. If this recurrence is not amenable to repeat surgical removal, PIPAC may be offered to help control disease progression and manage symptoms.

PIPAC as a Bridge to Cytoreductive Surgery

This represents one of the most exciting potential applications of PIPAC. Some patients initially have too much peritoneal tumor burden to safely remove surgically. In these cases, PIPAC may be used to shrink tumors and reduce disease extent. If significant response occurs, the patient may then become a candidate for cytoreductive surgery with curative intent.

Research suggests that approximately 10% to 15% of patients who initially could not undergo cytoreductive surgery may become surgical candidates after receiving multiple cycles of PIPAC. This “conversion to resectability” offers hope for patients who otherwise would have only palliative options.

PIPAC for Patients Not Suitable for Surgery

Many patients with peritoneal metastases are not candidates for cytoreductive surgery due to extensive disease, poor health status, or unfavorable tumor biology. For these individuals, PIPAC provides a treatment option that can help control disease and improve quality of life without requiring major surgery.

Clinical Trials and Research on PIPAC

PIPAC remains an investigational treatment in the United States, with ongoing research examining its safety, effectiveness, and optimal use. Clinical trials are exploring several important questions:

Current Research Focus Areas

Determining Optimal Patient Selection: Studies are working to identify which patients are most likely to benefit from PIPAC based on cancer type, disease extent, prior treatments, and biomarkers.

Combination Strategies: Researchers are examining how PIPAC works when combined with different systemic chemotherapy regimens, targeted therapies, and immunotherapies.

Treatment Timing: Some trials are investigating whether earlier use of PIPAC, before disease becomes extensive, might improve outcomes.

Prevention of Recurrence: Studies are exploring whether PIPAC after cytoreductive surgery might prevent or delay cancer recurrence.

Different Chemotherapy Medications: Research continues into which chemotherapy medications work best as PIPAC agents for different cancer types. However, any questions about specific medications should be discussed with your healthcare provider.

Quality of Life Assessment: Ongoing studies are carefully measuring how PIPAC affects patient well-being, symptom burden, and daily functioning.

Participating in Clinical Trials

Because PIPAC is still investigational in the United States, most treatment is currently offered through clinical trials. Participation in a clinical trial provides access to this innovative treatment while contributing to medical knowledge that will help future patients.

If you’re interested in PIPAC, discuss clinical trial options with your oncologist. They can help determine whether you might be eligible for available studies and assist with referral to participating centers. You can also search for trials through resources like ClinicalTrials.gov or contact cancer centers known to offer PIPAC research studies.

Access to PIPAC Treatment in the United States

PIPAC availability in the United States remains limited as the treatment is still in the investigational stage. Only a select number of specialized cancer centers offer PIPAC, primarily through clinical trials or as part of early adoption programs.

Centers Offering PIPAC

Several academic medical centers and comprehensive cancer centers have developed PIPAC programs. These institutions typically have extensive experience in treating peritoneal surface malignancies and have invested in the specialized equipment and training required to perform PIPAC safely.

When seeking PIPAC treatment, look for centers with:

• Multidisciplinary peritoneal surface malignancy programs
• Experience with both HIPEC and PIPAC procedures
• Active clinical trials or compassionate use programs
• Surgical oncologists trained in peritoneal cancer treatment
• Comprehensive supportive care services

Getting a Referral

If you’re interested in exploring PIPAC as a treatment option:

• Discuss with your current oncologist whether PIPAC might be appropriate for your situation
• Request a referral to a center offering PIPAC evaluation
• Gather your medical records, imaging studies, and pathology reports to bring to the consultation
• Prepare questions about potential benefits, risks, and logistics
• Consider factors like travel distance and ability to return for multiple treatments

Insurance Coverage and Financial Considerations

Because PIPAC is investigational, insurance coverage can be complex and varies significantly depending on how the treatment is accessed.

Clinical Trial Coverage

When PIPAC is provided through a clinical trial, the research sponsor or institution often covers costs directly related to the experimental treatment itself. However, standard care costs—such as routine imaging, lab work, hospitalizations, and systemic chemotherapy—may still be billed to insurance.

Under the Affordable Care Act, insurance companies cannot deny coverage for routine patient care costs when you participate in an approved clinical trial. This means that while the PIPAC procedure itself may be covered by the study, your insurance should still cover your standard cancer care.

Questions to Ask About Coverage

Before proceeding with PIPAC treatment, important financial questions include:

• Is the PIPAC procedure itself covered by the clinical trial or research program?
• Which costs will be billed to insurance versus covered by the study?
• Does your insurance cover out-of-network care if the PIPAC center is not in your network?
• What are the out-of-pocket costs you’ll be responsible for?
• Are travel and lodging expenses covered if the treatment center is far from home?
• Is financial assistance available through the hospital or cancer center?

Financial Assistance Resources

Many cancer centers have financial counselors who can:

• Help you understand what insurance will and won’t cover
• Identify assistance programs you might qualify for
• Work with you to develop a payment plan if needed
• Connect you with nonprofit organizations that help with travel, lodging, or treatment costs

Don’t hesitate to ask about financial assistance early in the process. Cancer centers understand that financial concerns are real and want to help patients access needed treatment.

Living with PIPAC Treatment: What to Expect

Treatment Schedule and Logistics

PIPAC treatment requires commitment to repeated procedures approximately every six to eight weeks. Planning ahead can help make the process more manageable:

• Schedule treatments in advance so you can arrange time off work and plan around other commitments
• If traveling to the treatment center, arrange transportation, lodging, and someone to accompany you
• Plan for 2-3 days around each treatment—procedure day plus recovery time
• Schedule follow-up appointments and monitoring between treatments at your local cancer center if possible

Managing Recovery Between Treatments

Most patients recover relatively quickly from each PIPAC procedure:

• First 24-48 hours: Expect some abdominal discomfort, possible shoulder pain, and fatigue. Pain medication and rest are usually sufficient for symptom management.
• Days 3-7: Most symptoms improve significantly. You may still tire easily and should avoid strenuous activity.
• Week 2 and beyond: Most patients feel back to their baseline and can resume normal activities as tolerated.

Maintaining Quality of Life

While undergoing PIPAC treatment:

• Stay as active as possible between treatments—gentle exercise like walking can help maintain strength and energy
• Maintain good nutrition, eating small frequent meals if appetite is reduced
• Stay connected with family and friends for emotional support
• Communicate openly with your healthcare team about symptoms or concerns
• Consider supportive services like counseling, support groups, or integrative therapies
• Plan activities you enjoy during the weeks between treatments when you’re feeling well

Questions to Ask Your Healthcare Team About PIPAC

If you’re considering PIPAC treatment, having detailed discussions with your medical team is essential. Important questions include:

About Your Specific Situation

• Am I a good candidate for PIPAC based on my cancer type and extent?
• What are the goals of PIPAC in my case—disease control, symptom relief, or bridge to surgery?
• How does PIPAC fit with my other treatments?
• What are my alternatives if I don’t pursue PIPAC?
• What results have you seen in patients similar to me?

About the Treatment Process

• How many PIPAC treatments do you anticipate I’ll need?
• How will we know if the treatment is working?
• What monitoring will happen between treatments?
• When might we decide to stop PIPAC treatments?
• What happens if the disease progresses despite PIPAC?

About Practical Considerations

• Will I need to stay in the hospital or can I go home the same day?
• When can I return to work or normal activities after each treatment?
• What restrictions will I have between treatments?
• Who should I call if I have concerns between treatments?
• What are the costs and what will insurance cover?

The Future of PIPAC Treatment

As research continues and experience with PIPAC grows, several exciting developments may expand its role in cancer care:

Broader Adoption: As more centers gain experience with PIPAC and outcomes data accumulates, this treatment may become more widely available beyond specialized academic centers.

Earlier Intervention: Current research focuses largely on advanced disease, but future studies may explore whether PIPAC used earlier in the disease course could prevent extensive peritoneal spread.

Regulatory Approval: If ongoing trials continue to show benefit, PIPAC may eventually receive regulatory approval, making it a standard treatment option rather than investigational therapy.

Combination Approaches: Research into combining PIPAC with novel therapies like immunotherapy or targeted agents may enhance effectiveness.

Personalized Treatment: Better understanding of which patients benefit most from PIPAC will allow more tailored treatment recommendations based on individual tumor characteristics and biomarkers.

Technical Refinements: Ongoing refinements in equipment, technique, and medication delivery may further improve outcomes and reduce side effects.

Making the Decision About PIPAC

Deciding whether to pursue PIPAC treatment is deeply personal and should involve careful consideration of multiple factors:

Medical Considerations: Work with your oncology team to understand whether PIPAC is medically appropriate for your situation and what realistic goals and outcomes might be expected.

Personal Values and Goals: Consider what’s most important to you—extending life, maintaining quality of life, trying all available options, or minimizing treatment burden. PIPAC may align well with some goals but not others.

Practical Factors: Honestly assess whether you can commit to repeated treatments, travel if necessary, and manage the logistics involved.

Support System: Consider what support you have from family and friends to help you through the treatment process.

Financial Impact: Understand the potential costs and how they fit with your financial situation and resources.

There’s no single right answer for everyone. Some patients feel strongly about pursuing every available treatment option and find hope in trying an innovative approach like PIPAC. Others may prefer less intensive approaches that maximize quality time at home. Both perspectives are valid, and your healthcare team should support whatever decision aligns with your values and goals.

Conclusion

Pressurized intraperitoneal aerosol chemotherapy represents an innovative addition to the treatment options available for patients with peritoneal metastases. By delivering chemotherapy directly to tumor sites as a pressurized mist, PIPAC offers potential benefits including disease control, symptom relief, and improved quality of life, all with a minimally invasive approach and manageable side effects.

While still considered investigational in the United States and primarily available through clinical trials, PIPAC has shown promising results in research studies and clinical experience from centers around the world. For carefully selected patients with advanced peritoneal cancer, particularly when other treatment options are limited, PIPAC may provide meaningful benefit.

As with any cancer treatment decision, pursuing PIPAC should involve thorough discussion with your healthcare team, realistic understanding of potential benefits and risks, and careful consideration of your personal goals and circumstances. If you’re interested in learning whether PIPAC might be appropriate for you, talk with your oncologist about evaluation at a center offering this innovative treatment approach.

Sources:

• Mayo Clinic – Cancer Treatment Information
• National Cancer Institute – Clinical Trials and Treatment Information
• American Cancer Society – Cancer Treatment Resources
• PubMed Central – Medical Research on PIPAC
• American Society of Clinical Oncology – Peritoneal Cancer Treatment