Our first case is a 35-year-old woman who was first diagnosed with stage 1B1 endocervical adenocarcinoma and underwent robotic assisted radical hysterectomy and bilateral salpingo-oophorectomy followed by surveillance. Her surveillance was notable for physical exams in a facility closer to her home. She underwent PET scan 4 months after resection which was negative for disease recurrence. 10 months later, she presented with abdominal bloating and was found to have an abdominal mass with peritoneal carcinomatosis and malignant ascites without disease in her chest. She was initiated on carboplatin/paclitaxel/bevacizumab for 6 cycles [13]. Notably she received carboplatin instead of cisplatin due to anaphylaxis to fosaprepitant. Her genomic testing demonstrated no actionable alterations though identified ARID1A mutation, PIK3CA mutation and PTEN mutation, also of note her tumor was microsatellite stable and the tumor mutational burden low. She had a significant partial response to chemotherapy with resolution of symptoms and ascites though a persistent pelvic mass. She then underwent cytoreductive surgery with HIPEC with cisplatin and paclitaxel. Disease was resected via omentectomy, bilateral salpingo-oophorectomy, appendectomy, and removal of intra-abdominal tumor that was greater than 10 cm. Once all the disease was removed, 3 liters of plasmalyte were instilled and circulated at 1400mL/minute. Once temperatures were between 42-43C, cisplatin 100mg/m2 and paclitaxel 175mg/m2 was instilled. The abdomen was agitated for 90 minutes and then all the fluid was removed via outflow catheters. Following HIPEC, she completed 3 more cycles of carboplatin/paclitaxel. She then transitioned to bevacizumab maintenance for 13 cycles. She is currently in surveillance with CT imaging and exams every 3 months and remains without evidence of disease 24 months since HIPEC therapy.

Our second case is a 33-year-old woman who was first diagnosed with stage IA1 cervical adenocarcinoma. The patient underwent cold knife conization with multiple local recurrences. During her course, she received a total of 4 cold knife conizations in attempts to preserve fertility. Three years after diagnosis with stage 1A1 cervical adenocarcinoma with positive endocervical curettage and deep endocervical margins, the patient underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy followed by adjuvant chemoradiation with cisplatin given high risk feature of close margins. She started on a surveillance regimen with exams every three months. Unfortunately, 16 months into surveillance, the patient presented with abdominal distension and pain. CT torso demonstrated large volume ascites with extensive peritoneal nodularity and omental caking without evidence of disease in her chest. She underwent diagnostic laparoscopy and omental biopsy where pathology confirmed recurrent cervical adenocarcinoma. She received cisplatin/paclitaxel/bevacizumab for 6 cycles with significant partial response yet had residual peritoneal carcinomatosis. Her genomic testing sequencing from tumor resection demonstrated genomic alterations in FANCC, MLL2 and SMAD4. Microsatellite status and tumor mutation burden could not be determined. After a failed attempt to qualify for an immunotherapy clinical trial due to the adenocarcinoma histology, she received an additional cycle of paclitaxel and bevacizumab and then underwent cytoreductive surgery with HIPEC. She underwent cholecystectomy, appendectomy, splenectomy, omentectomy, bilateral oophorectomy and right sided peritoneal stripping. Once all visible disease was removed, 3 liters of plasmalyte was instilled with fluid circulation at 1500mL/minute until fluid temperature reached 42-43C. Then, 30mg mitomycin-C and 75mg/m2 cisplatin were instilled. Patient received sodium thiosulfate as a bolus and then as a continuous drip for 6 hours per weight-based protocol. 60 minutes into the instillation, the patient received another 10mg of mitomycin-C. During this time, the abdomen was agitated. All the fluid was drained via outflow catheters after 90 minutes. She did not receive any adjuvant therapy following HIPEC. Surveillance consisted of CT/MRI imaging and exam every 3 months. She remained disease free for 15 months from time of HIPEC. Unfortunately, she developed biliary disease as demonstrated on CT torso: new metastatic infiltrative mass/lymph node involving the hepatic hilum causing moderate intrahepatic biliary ductal dilation and a new focus of peritoneal carcinomatosis.  She was started on cisplatin/bevacizumab given the platinum free interval; however, she had progression of disease and then treated with nivolumab/ipilimumab with initial response but then further disease progression. She ultimately passed away over 3 years from her initial diagnosis of recurrent metastatic disease.

1st Patient Pre and Post CRS/HIPEC