Finding the Right Surgeon

Where I Am Right Now

Stage IV colorectal adenocarcinoma. The short version: diagnosed, completed 12 cycles of FOLFOX, recurred in the liver nine months later, reclassified as Stage IV. Now on FOLFIRI — with a measurable response.

My latest MRI came back better than expected.

The cancer deposits — subcapsular implants on the liver surface and two pelvic implants — have all shrunk significantly. One liver implant went from 28×21mm down to 15×3mm. That is not a rounding error. The chemotherapy is working.

My team at Champalimaud Foundation in Lisbon has indicated that Cytoreductive Surgery (CRS) ± HIPEC is likely after chemotherapy concludes.

So I did what I always do. I started researching.

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What CRS/HIPEC Actually Is

CRS — Cytoreductive Surgery. The surgeon opens the abdominal cavity and removes every visible deposit of cancer on the peritoneal surface: the lining of the abdomen. That can mean portions of the colon, the omentum, the peritoneum itself, anything where disease is found. It typically takes 6–10 hours.

HIPEC — Hyperthermic Intraperitoneal Chemotherapy — happens next, while you're still on the table. A heated chemotherapy solution circulates through the abdominal cavity for roughly 90 minutes, targeting microscopic cancer cells that surgery can't see or reach. The heat drives the chemotherapy deeper into tissue than intravenous delivery can.

The volume-outcome relationship in CRS/HIPEC is well-documented. There is a known institutional learning curve of 140–220 cases before outcomes stabilize. This is not a surgery where experience is optional.

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Why My MRI Results Changed the Picture

The MRI report used a phrase I had to look up: implantes subcapsulares hepáticos.

Subcapsular hepatic implants.

It also noted — explicitly — no intraparenchymal lesions. That's the part that matters.

Here's the difference. Cancer inside the liver tissue requires a separate surgical team and a more complex operation. Cancer on the surface of the liver is part of the peritoneal surface — the same territory CRS/HIPEC is designed to treat. One surgical team. One operation.

What initially looked like a multi-site problem requiring two surgical teams is, based on the imaging, a peritoneal surface disease problem.

That's exactly the right box to be in.

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The Number That Determines Everything: PCI

Patient selection for CRS/HIPEC hinges on a score called the Peritoneal Cancer Index — PCI. It quantifies disease burden across 13 regions of the abdominal cavity, scored 0–39.

Based on current imaging — four implants, all shrinking, no ascites, no diffuse peritoneal thickening — my radiographic PCI appears low. That is the direction you want to be moving.

Imaging consistently underestimates true operative PCI, which is one reason high-volume centers often do a staging laparoscopy before committing to full open CRS. That is a reasonable question to put to any surgical team reviewing my case.

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Finding the Right Centers

I researched the global leaders in CRS/HIPEC and filtered for my specific disease — colorectal peritoneal adenocarcinoma — because center rankings differ significantly by tumor type. Here's what I found.

Atrium Health Wake Forest Baptist — Winston-Salem, NC

Surgeon: Dr. Edward A. Levine, Chief of Surgical Oncology.

The longest continuous CRS/HIPEC program in the United States, running since December 1991. Over 2,000 total institutional procedures. Levine personally has performed more than 1,000. Their published colorectal-specific dataset is among the most cited globally for this disease. PSOGI-recognized center. No referral required — international patients can contact directly and provide records in advance.

Medical Center Boulevard, 4th Floor, Winston-Salem, NC 27157
Phone: (336) 716-4276 | Direct: (336) 716-0545
wakehealth.edu

Memorial Sloan Kettering — New York, NY

World-leading cancer center with a dedicated Peritoneal Surface Malignancies program and the strongest combined hepatobiliary and peritoneal surgical team in the US — relevant if combined operations become necessary.

MSK is leading the ICARuS trial — the largest prospective US study on intraperitoneal chemotherapy after cytoreductive surgery for colorectal and appendiceal cancer.

One important note: MSK has stopped adding HIPEC to CRS for colorectal peritoneal metastases. Their decision is based on results from the phase 3 PRODIGE 7 trial and their own ICARuS data, both of which showed no survival benefit from adding HIPEC to surgery. MSK now favors CRS alone or CRS + EPIC — early post-operative intraperitoneal chemotherapy.

This does not make them a worse choice. It makes them a data-driven one.

HIPEC's benefit in colorectal disease specifically is actively debated at the highest levels of surgical oncology. The two most rigorous completed trials have not confirmed a survival advantage. Any patient evaluating options should be having this conversation directly with their surgical team.

1275 York Avenue, New York, NY 10065
International Center: +1 (332) 900-5155
International@mskcc.org | mskcc.org/appointments/international

No referral required. Interpreters and medical record translation available. Response target: within one business day.

Champalimaud Foundation — Lisbon

This is where I am currently receiving chemotherapy, and where my oncology relationship is established. It is an excellent institution for cancer care broadly. The surgical unit includes credentialed colorectal surgeons, and they offer CRS/HIPEC as part of the digestive surgical service.

The honest gap is this: Champalimaud does not publish CRS/HIPEC volume data. It is not listed as a PSOGI-recognized reference center. HIPEC is embedded within a broader surgical program rather than run as a dedicated peritoneal oncology specialty.

None of that means the care would be poor. But it means I cannot verify the center against the same criteria I can apply to Wake Forest or MSK.

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Questions to Ask Any Center Before Committing

How many CRS/HIPEC cases does your program perform per year?
What is your CC-0 — complete cytoreduction — rate for colorectal peritoneal disease?
What HIPEC agent do you use for patients with prior oxaliplatin exposure, and why?
What is your 30-day and 90-day morbidity and mortality for combined cases?
Does your multidisciplinary review include a dedicated peritoneal surgeon, not just a colorectal or general surgical oncologist?

If those questions can't be answered with specific institutional numbers, that is informative in itself.

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What I'm Doing Next and When

The standard patient mistake is treating a surgical consultation as something that happens after chemotherapy fails or ends. Patients who arrive at high-volume centers mid-response — while disease is still shrinking and the surgical team can document the trajectory — have better-established care relationships and more options when the decision point arrives.

I am currently on FOLFIRI with a strong documented response. My next imaging cycle is the clinical inflection point. If disease remains stable or continues shrinking, surgical evaluation becomes the immediate next step.

My plan:

Contact Wake Forest and MSK simultaneously for international patient surgical consultations — not after chemo ends, now.
Send imaging, FoundationOne CDx genomic report, and full chemotherapy history to both centers.
Ask Champalimaud directly for their program volume and designated peritoneal surgeon.
Confirm from my oncologist: are the hepatic lesions purely subcapsular, or is there any intraparenchymal component? That one clarification determines surgical team composition.
Ask any surgical team about HIPEC drug selection given 12 prior cycles of oxaliplatin — mitomycin C is the likely preferred agent, and I want to see this addressed in the pre-operative plan.

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One More Clinical Detail Worth Noting

My genomic profile includes a KRAS G12V mutation. This eliminates EGFR inhibitors — cetuximab, panitumumab — as treatment options. It does not directly worsen CRS/HIPEC outcomes. In multivariate models, KRAS mutation is consistently the weakest prognostic variable once PCI and completeness of cytoreduction are accounted for.

It does matter for HIPEC drug planning. My prior oxaliplatin exposure and KRAS status together support the case for mitomycin C-based HIPEC rather than an oxaliplatin perfusion. This should be pre-planned, not decided in the operating room.

Separately: KRAS G12V is now an active drug-development target. Trials for G12V-specific inhibitors are running. The FoundationOne CDx data is archived and positions me for trial eligibility screening when the time comes.

My Journey