The combination of complete cytoreductive surgery and perioperative intraperitoneal chemotherapy provides the only chance for long-term survival for selected patients diagnosed with a variety of peritoneal neoplasms, either primary or secondary to digestive or gynecologic malignancy. Hyperthermic intraperitoneal chemotherapy (HIPEC) delivered in the operating room once the cytoreductive surgical procedure is finalized, constitutes the most common form of administration of perioperative intraperitoneal chemotherapy. This may be complemented in some instances with early postoperative intraperitoneal chemotherapy (EPIC). HIPEC combines the pharmacokinetic advantage inherent to the intracavitary delivery of certain cytotoxic drugs, which results in regional dose intensification, with the direct cytotoxic effect of hyperthermia. Hyperthermia exhibits a selective cell-killing effect in malignant cells by itself, potentiates the cytotoxic effect of certain chemotherapy agents and enhances the tissue penetration of the administered drug. The chemotherapeutic agents employed in HIPEC need to have a cell cycle nonspecific mechanism of action and should ideally show a heat-synergistic cytotoxic effect. Delivery of HIPEC requires an apparatus that heats and circulates the chemotherapeutic solution so that a stable temperature is maintained in the peritoneal cavity during the procedure. An open abdomen (Coliseum) or closed abdomen technique may be used, with no significant differences in efficacy proven to date. Specific technical training and a solid knowledge of regional chemotherapy management are required. Concerns about safety of the procedure for operating room personnel are expected but are manageable if universal precautions and standard chemotherapy handling procedures are used. Different HIPEC drug regimens and dosages are currently in use. A tendency for concurrent intravenous chemotherapy administration (bidirectional chemotherapy, so-called "HIPEC plus") has been observed in recent years, with the aim to further enhance the cytotoxic potential of HIPEC. Future trials to ascertain the ideal HIPEC regimen in different diseases and to evaluate the efficacy of new drugs or drug combinations in this context are warranted.

Imaging studies are crucial in the evaluation of patients with suspected or known peritoneal cancerous dissemination. Despite the major progress that has occurred in radiological technology in the last few years, adequate and early detection of peritoneal surface disease remains a challenge. Improvements in spatial resolution are still insufficient to detect small volume peritoneal implants, often resulting in an underestimation of peritoneal disease burden, as assessed at subsequent surgical exploration. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has provided unprecedented results in the management of peritoneal-based neoplasms, provided that a complete (adequate) cytoreduction is achieved. Diagnostic imaging tests are used to select patients who may benefit from this combined treatment by ruling out extraperitoneal involvement and signs of unresectable peritoneal disease. Furthermore, a careful assessment of the disease distribution within the peritoneal cavity, guided by a deep knowledge of the disease's clinical and biological behavior helps in planning the surgical procedure. Close interaction and cooperation between surgeons and radiologists is of utmost importance in this regard, and dedicated, motivated radiologists are required. Contrast-enhanced, multidetector computed tomography scan remains the standard imaging modality in the assessment of peritoneal carcinomatosis. Magnetic resonance imaging may offer complementary valuable data. Positron emission tomography (PET) has a more limited role, its main indication being the detection of unsuspected extraperitoneal involvement in nonmucinous neoplasms.