Could a New Scoring System Help Doctors Decide When Repeat CRS/HIPEC Surgery Is Appropriate?
Manoğlu B, Sökmen S, Bişgin T ... Re-cytoreduction predictive Index(RECPI)-based Immune-Ascites(IMA) scoring system for peritoneal metastatic disease: A paired-analysis of surgical and oncological outcomes. European Journal of Surgical Oncology, 2026; 52
For patients whose cancer has returned after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), one of the most difficult questions is whether another surgery could be beneficial. While repeat surgery may be an option for some patients, it is a complex procedure that requires careful consideration of potential benefits and risks.
A 2026 study published in the European Journal of Surgical Oncology explored a new scoring system designed to help specialists identify patients who may be candidates for repeat CRS/HIPEC and better predict their risk of complications. The findings suggest that certain blood tests and the presence of fluid in the abdomen may provide valuable information when making these treatment decisions.
Understanding the Study
Cytoreductive surgery is a procedure that removes visible cancer from the abdominal cavity. It is sometimes combined with HIPEC, a treatment that circulates heated chemotherapy directly within the abdomen during surgery.
For certain patients with cancers that have spread to the lining of the abdomen, known as peritoneal metastases, CRS/HIPEC may be an important treatment option. However, cancer can sometimes return after treatment.
When this happens, specialists must determine whether another operation is appropriate. This decision depends on several factors, including the extent and location of the cancer, the patient's overall health, previous treatments, and the likelihood that the cancer can be completely removed.
Researchers at Dokuz Eylül University in Turkey examined whether a new scoring system could help guide these decisions.
What Did the Researchers Study?
The researchers reviewed information from 718 patients who underwent CRS/HIPEC between 2007 and 2022. Of these patients, 64 (approximately 9%) underwent repeat cytoreductive surgery.
They developed a scoring approach called the Re-Cytoreduction Predictive Index (RECPI), incorporating an Immune-Ascites (IMA) score.
The score focused on three measures:
Inflammation in the body: Blood test results involving C-reactive protein (CRP), a marker of inflammation.
Nutritional and inflammatory status: Albumin, a protein in the blood that can reflect nutritional status, inflammation, and overall health.
Ascites: The buildup of fluid in the abdomen, which can occur in patients with advanced abdominal cancers.
By evaluating these factors together, researchers hoped to identify patterns that could help predict surgical risks and support decisions about repeat treatment.
What Did the Study Find?
The researchers found that their scoring system was associated with differences in patients' surgical outcomes.
In particular, patients with an IMA score of two or higher before their initial CRS/HIPEC surgery had significantly higher rates of serious postoperative complications and death following surgery.
The scoring system also showed an association with which patients underwent repeat cytoreductive surgery. However, because higher scores were also linked to greater surgical risk, the findings should not be interpreted to mean that a higher score automatically makes someone a better candidate for repeat surgery.
Overall, the study suggests that combining information about inflammation, albumin levels, and abdominal fluid may help specialists better understand a patient's risk before undertaking a major operation.
What Does This Mean for Patients?
The findings reinforce an important message: Deciding whether to undergo repeat CRS/HIPEC requires more than evaluating how much cancer is present.
A patient's overall health, inflammation levels, nutritional status, and other medical factors may influence how safely they can undergo surgery.
For patients whose cancer has returned, this research offers hope that specialists may eventually have better tools to personalize treatment recommendations.
However, this scoring system is still being studied. The findings do not establish that using the IMA score improves survival or that the score should determine treatment decisions on its own.
Why Is This Research Important?
Repeat CRS/HIPEC can be particularly challenging because patients have already undergone major abdominal surgery. Scar tissue, changes in anatomy, and the patient's physical condition may make another procedure more complicated.
Having additional tools to estimate surgical risk could help physicians identify patients who may benefit from another operation while also recognizing those who face a greater likelihood of serious complications.
Importantly, this was a retrospective analysis from a single medical center, and only 64 patients underwent repeat surgery. Larger studies involving different cancer types and treatment centers are needed to confirm how reliably the scoring system works.
The Alliance's Takeaway
When cancer returns after CRS/HIPEC, a second surgery may still be an option for carefully selected patients.
This research highlights the importance of individualized treatment planning and evaluation by specialists experienced in peritoneal surface malignancies.
Patients facing recurrent disease should feel empowered to ask whether repeat CRS/HIPEC is appropriate, what factors influence their surgical risk, and whether a second opinion at a specialized center could help clarify their options.
While the new scoring system is not yet an established standard for determining treatment, it represents another step toward more informed, personalized decision-making for patients with advanced abdominal cancers.
