Interval debulking with HIPEC in patient with VP shunt

Abstract

Background

Hyperthermic intraperitoneal chemotherapy (HIPEC) combined with cytoreductive surgery has demonstrated survival benefits in advanced ovarian cancer. However, the safety of HIPEC administration in patients with indwelling ventriculoperitoneal (VP) shunts remains unknown, as no prior cases have been reported. Theoretical risks include shunt infection, chemical ventriculitis, and potential central nervous system (CNS) metastasis via retrograde flow through the shunt catheter. The absence of established management guidelines poses a significant challenge for clinicians treating ovarian cancer patients with concurrent VP shunts.

Case Presentation

A 60-year-old G1P1 with a 6-year history of a programmable VP shunt for hydrocephalus secondary to cerebellar hemangioblastoma presented with high-grade serous ovarian carcinoma, FIGO stage IIIA2. Following neoadjuvant chemotherapy, she underwent interval debulking surgery with cisplatin-based HIPEC. A multidisciplinary approach was employed: neurosurgery externalized the VP shunt catheter from the peritoneal cavity and wrapped it in metronidazole-soaked gauze during HIPEC administration and the shunt was replaced at case completion. Postoperative vancomycin, cefepime, and metronidazole were provided for five days for meningitis prophylaxis. The patient experienced no shunt-related complications and was discharged on postoperative day 4. At 10-month follow-up, she demonstrated excellent oncologic response with CA-125 normalization and no evidence of shunt malfunction or CNS involvement.

Conclusion

This case demonstrates that HIPEC can be safely performed in patients with indwelling VP shunts when a multidisciplinary strategy incorporating intraoperative shunt externalization and antimicrobial prophylaxis is utilized. This approach expands treatment options for ovarian cancer patients with VP shunts who may otherwise be excluded from potentially beneficial HIPEC therapy.

Highlights

• •There is a dearth of literature on the administration of HIPEC in patients with in-dwelling VP shunts.
• •Multidisciplinary approach was taken to plan & execute administration of HIPEC while minimizing risks associated with VP shunt.
• •Subsequent tracking of patient postoperatively demonstrates strategy was effective and safe.

1. Introduction

Ovarian cancer is the leading cause of mortality among gynecologic malignancies despite accounting for only approximately 17% of new gynecologic cancers each year (Rock et al., 2022). This is due to the majority of cases being advanced stage at the time of presentation (Aronson et al., 2023). The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery has been shown to significantly improve overall (∼45 vs 33 months) and progression-free survival (∼14 vs 10 months) (Aronson et al., 2023).

Ventriculoperitoneal (VP) shunts are typically utilized for the treatment of hydrocephalus regardless of etiology (Bauer et al., 2020). While there has been documented evidence of open and laparoscopic surgeries performed safely in patients with VP shunts in place, there is a dearth of literature describing the use of HIPEC in this patient population (Hoy et al., 2025; Fraser et al., 2009). Considerations to be given in this context are the risk of retrograde spreading through the shunt leading to CNS metastasis and infection (Eralp et al., 2008; Tunkel et al., 2017).

Given the absence of prior reports, the patient was counseled extensively regarding the novel nature of this procedure. She was informed that no prior cases of HIPEC administration in a patient with an indwelling VP shunt had been reported in the literature. The specific risks discussed included shunt infection, chemical ventriculitis from retrograde flow of heated cisplatin, potential CNS tumor seeding via the shunt catheter, and shunt malfunction. The patient understood and accepted these risks after multidisciplinary discussion and provided written informed consent.

Here we present possibly the first documented case of a patient with high-grade serous ovarian carcinoma treated successfully with interval debulking surgery and HIPEC with an in-dwelling VP shunt.

2. Case presentation

This is a 65-year-old G1P1 with a past medical history of hypertension, type 1 diabetes, and cerebellar hemangioblastoma status post a programmable VP shunt placement in 2019, who presented with abdominal bloating, fullness, nausea, and vomiting. CT scan showed a 15 cm cystic ovarian mass, extensive omental and peritoneal disease, ascites, and pleural effusion. CA-125 was as high as 1592 U/mL. Laparoscopic biopsies of liver, peritoneum, omentum, and fallopian tube all confirmed high-grade serous ovarian carcinoma, FIGO stage IIIA2. Due to the extent of the disease, the size of the mass, and the fact that she had a low GFR and elevated creatinine, she was deemed a poor candidate for primary cytoreductive surgery. She received six cycles of neoadjuvant chemotherapy with carboplatin, paclitaxel, and bevacizumab, with bevacizumab withheld during cycles 2, 3 and 5 due to proteinuria and therefore, limited response initially.

She subsequently demonstrated excellent response to therapy with resolution of symptoms and significant tumor reduction.

Given the patient's medical history and extent of disease, a multidisciplinary approach involving gynecologic oncology, urology, colorectal surgery, endocrinology, and neurosurgery was utilized to ensure safe surgical planning and administration of HIPEC. Concerns that were addressed included minimizing the risk of CNS seeding via VP shunt, prevention of shunt infection, and maintenance of shunt function during and after surgery.

Interval debulking surgery was performed approximately five weeks after her sixth cycle of chemotherapy. Urology was present for bilateral ureteral stent placement. Neurosurgery evaluated the VP shunt at the beginning of the case and determined that it was functioning appropriately. The distal catheter was carefully dissected, wrapped in metronidazole-soaked gauze, and externalized from the peritoneal cavity to prevent exposure to the heated chemotherapy solution [Fig. 1].

Fig. 1.

Surgical field with externalized VP shunt.

The patient then underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic and infragastric omentectomy, bilateral pelvic lymphadenectomy, appendectomy, and optimal tumor debulking. HIPEC was then administered using the open abdomen technique with cisplatin 100 mg/m² at a flow rate of 1 L per minute for 90 min at 40–42 °C. The cisplatin dose was divided: 50% initially, 25% at 30 min, and 25% at 60 min, consistent with the OVHIPEC-1 protocol (Aronson et al., 2023; van Driel et al., 2018). Throughout the HIPEC procedure, the VP shunt catheter remained wrapped in metronidazole-saturated gauze and externalized from the peritoneal cavity. Following completion of HIPEC and peritoneal lavage with roughly 1000 mL of normal saline was used, the VP shunt catheter was repositioned within the peritoneum under neurosurgical guidance. Colorectal surgery was present to address any disease in the upper abdomen and small bowel, which included resection of falciform ligament, cholecystectomy, resection of right Gerota's fascia implant, and resection of right upper quadrant peritoneal implant.

Postoperatively, prophylactic antibiotics were initiated for five days for meningitis prevention, including vancomycin, cefepime, and metronidazole, based on current guidelines (Gaillard et al., 2025). The patient's hospital stay was uncomplicated with no evidence of shunt malfunction, infection, or neurologic symptoms. She was discharged home on postoperative day 2.

The patient had serial clinic visits, initially at 2–3-week intervals, then 3-month intervals with no complications or concerns. Repeat CA-125 results showed consistent downtrending with a nadir of high 20s U/mL. The patient received three additional cycles of adjuvant chemotherapy. She received three additional CT scans at 3-month intervals, initially demonstrating possible recurrent disease, but this was resolved on subsequent imaging. There was no other evidence of new or recurrent intra-abdominal disease, suggesting a favorable response to treatment. The VP shunt has remained functional throughout the follow-up period with no evidence of infection, malfunction, or CNS involvement. The patient has experienced no neurological symptoms.

3. Discussion

This report represents perhaps the first case of successful administration of HIPEC in a patient with an indwelling VP shunt. The OVHIPEC-1 trial demonstrated the significant improvement in survival outcomes that can be generated by the addition of HIPEC to interval cytoreductive surgery in treating stage III ovarian cancer. HIPEC plus surgery produced a hazard ratio of 0.70 for overall survival at 10-year follow-up (Aronson et al., 2023). Therefore, the American Society of Clinical Oncology (ASCO) updated its clinical guidelines to support the use of HIPEC with interval cytoreductive surgery in appropriate patients (Mortellaro et al., 2009). Using a multidisciplinary approach, the presence of an indwelling VP shunt was determined not to be an indication to withhold this beneficial additive to surgery.

The HIPEC protocol utilized included cisplatin 100 mg/m2 administered over 90 min at 40 degrees Celsius. Sodium thiosulfate was used throughout the procedures for nephroprotection.

Several considerations were taken to minimize risk during and after surgery. Previous literature on intraperitoneal procedures in patients with VP shunts did not increase the risk of infection (Fraser et al., 2009; Pietzner et al., 2009). We took the approach of externalizing and protecting the shunt catheter during HIPEC administration, which prevented direct exposure to the heated cisplatin solution. We also wrapped the catheter in metronidazole-soaked gauze during the procedure, and, postoperatively, the patient was started on broad-spectrum antimicrobial prophylaxis targeting common shunt pathogens (vancomycin, cefepime, metronidazole) and was administered based on current guidelines (Tunkel et al., 2017).

While CNS metastasis from ovarian cancer is typically low (1–2%), case reports have described this type of dissemination via VP shunts (Eralp et al., 2008; Marchetti et al., 2011). Our approach was externalizing the catheter during HIPEC administration and thorough irrigation of the peritoneum prior to repositioning the shunt. Outpatient follow-up with our clinic and neurosurgery evaluated neurological function, and no deficits were identified.

While no prior literature of HIPEC with indwelling VP shunts has been identified, there are several cases of laparoscopic procedures with VP shunts that provide reassuring safety outcomes. Multiple studies have shown that pneumoperitoneum and intraperitoneal procedures can be performed safely without requiring externalizing or clamping the shunt (Fraser et al., 2009; Jackman et al., 2000). However, HIPEC presents specific concerns due to the prolonged exposure to heated chemotherapy solution, hence our more conservative approach to externalizing and wrapping the shunt.

Postoperatively, the patient had favorable responses to surgery and HIPEC. Her CA-125 normalized, and multiple repeat imaging studies demonstrated improvement in tumor burden without recurrence of disease or neurological dysfunction. While a longer follow-up will be warranted to better assess the use of HIPEC on oncologic outcomes for this patient, data thus far have been promising and have demonstrated that HIPEC can safely be administered to patients with indwelling VP shunts, provided appropriate antibiotics and a multidisciplinary approach are used for surgical planning.

4. Conclusions

This case demonstrates that HIPEC can be safely performed in patients with indwelling VP shunts, utilizing a multidisciplinary approach with careful intraoperative shunt management and appropriate antimicrobial prophylaxis. This expands treatment options for ovarian cancer patients with VP shunts who may otherwise be excluded from potentially beneficial HIPEC therapy.

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

CRediT authorship contribution statement

R. Shanoada: Writing – review & editing, Writing – original draft, Data curation, Conceptualization. J. Stephens: Writing – review & editing, Supervision, Conceptualization. Z.R. Al-Wahab: Writing – review & editing, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.