For women whose ovarian cancer has come back, recurred after initial surgery and chemotherapy, the conversation in most Indian hospitals quickly narrows. More chemotherapy. Possibly targeted therapy or PARP inhibitors. Palliative care if responses are poor. The mental model is “manage the recurrence” rather than “consider further interventions.”
For a meaningful minority of these patients, that narrowing is premature. A procedure called PIPAC, pressurised intraperitoneal aerosol chemotherapy, has matured into a real treatment option for selected recurrent ovarian and peritoneal cancers. It’s not yet standard of care, and it’s not for everyone, but it exists, it’s available at a small number of Indian centres, and most patients aren’t told about it.
This article explains what PIPAC is, who it’s for, and what the realistic outcomes look like.
What PIPAC is
PIPAC stands for Pressurised Intraperitoneal Aerosol Chemotherapy. The procedure is performed laparoscopically, through small incisions, under general anaesthesia. The surgeon:
- Inserts laparoscopic ports into the abdomen
- Inflates the abdomen with carbon dioxide gas (as in routine laparoscopy)
- Sprays a controlled dose of chemotherapy in aerosol form into the pressurised abdominal cavity
- Allows the aerosol to settle on all internal surfaces for 30 minutes
- Removes the gas and closes the small incisions
The whole procedure takes 60–90 minutes. Hospital stay is typically 2–3 days. Recovery is meaningfully faster than open surgery, patients are usually back to baseline within a week.
PIPAC is repeated every 6 weeks, typically for 3 cycles, often in combination with systemic intravenous chemotherapy.
Why it might work where IV chemotherapy doesn’t
For recurrent ovarian and peritoneal cancer, the disease often persists as small surface deposits on the peritoneum and abdominal organs. These deposits are technically present but functionally “invisible” to intravenous chemotherapy because:
- IV chemotherapy reaches surface deposits poorly. The peritoneum is a barrier; tumour blood supply is variable.
- IV chemotherapy is dose-limited by systemic toxicity. The dose that reaches the peritoneal surface is a fraction of the dose given.
- Aerosolised intraperitoneal delivery achieves much higher local concentrations at the peritoneal surface.
PIPAC capitalises on this. By delivering chemotherapy in aerosol form under pressure directly to the peritoneal cavity, it achieves drug concentrations at the disease surfaces that IV chemotherapy can’t match.
The trade-off is that PIPAC is local treatment, it doesn’t address systemic disease. That’s why it’s most often combined with continued systemic chemotherapy in a “bidirectional” approach.
Who’s a candidate
PIPAC is most clearly indicated for:
- Recurrent ovarian, fallopian tube, or primary peritoneal cancer with peritoneal-predominant disease
- Cancers where systemic chemotherapy alone has reached its useful limit but the patient is otherwise fit
- Patients who are not candidates for further cytoreductive surgery because of disease distribution but who could tolerate a 60–90 minute laparoscopic procedure
- Selected patients with primary disease, particularly those with significant peritoneal disease that makes complete cytoreduction unlikely up front; here PIPAC may be used as a neoadjuvant approach before considering cytoreduction
PIPAC is not appropriate for:
- Patients with significant systemic (extra-abdominal) disease where the dominant problem isn’t peritoneal
- Patients too frail to tolerate general anaesthesia and laparoscopy
- Patients with severe peritoneal adhesions making safe laparoscopic access impossible
- Cancers where the underlying biology suggests poor response to chemotherapy regardless of route
Patient selection by a multidisciplinary tumour board is essential. PIPAC is one of the procedures where the wrong patient produces no benefit and adds risk.
What the realistic outcomes look like
International series and emerging Indian data on PIPAC for recurrent ovarian cancer show:
- Symptomatic improvement, relief of ascites, abdominal distension, and disease-related abdominal pain in a majority of treated patients
- Histological response, biopsy of peritoneal nodules after 2–3 PIPAC cycles shows tumour regression in a meaningful proportion of cases
- Survival benefit, measurable extension of survival in selected patient subgroups, particularly when PIPAC is used early in the recurrence trajectory rather than as a last-resort option
- Quality of life, generally maintained or improved during PIPAC therapy
The outcomes are best when PIPAC is used as part of an integrated, multidisciplinary plan rather than as a salvage attempt after all other options have been exhausted. Earlier introduction in the recurrence pathway produces better numbers.
The bidirectional approach
One of the more interesting developments in PIPAC has been the bidirectional chemotherapy concept, combining PIPAC (local) with intravenous chemotherapy (systemic) in a coordinated regimen. The rationale: PIPAC handles the peritoneal surface disease, IV chemotherapy handles the systemic component, and together the combination produces better disease control than either alone.
Published work on bi-directional chemotherapy with PIPAC and intravenous route in advanced primary epithelial ovarian cancer has documented this approach in Indian patients. The clinical experience is still maturing, but the early signals suggest this is one of the more promising directions for advanced ovarian cancer management.
For families considering PIPAC, asking specifically about whether the centre uses a bidirectional approach is a useful question. The answer reveals the depth of the centre’s experience with the procedure.
What it costs
PIPAC in India costs substantially less than open cytoreductive surgery with HIPEC. Typical package cost:
- Ahmedabad tertiary: ₹1.5–3 lakh per cycle
- Mumbai / Delhi premium tertiary: ₹3–5 lakh per cycle
- A complete 3-cycle PIPAC course: ₹5–12 lakh, depending on city and centre
Insurance coverage for PIPAC has expanded but is still less consistent than for HIPEC. Pre-authorisation is essential. Some insurers cover it within the broader cancer treatment package; others require case-by-case appeal.
Where it’s available in India
PIPAC is performed at a very small number of Indian centres in 2026, fewer than ten total, concentrated in Mumbai, Delhi, Bengaluru, and a small number of other tertiary cities. Ahmedabad is one of the cities where it’s offered, which makes PIPAC for recurrent ovarian cancer accessible for Gujarat and central-India patients without requiring a Mumbai trip.
For most Indian patients with recurrent ovarian cancer, knowing whether their case is appropriate for PIPAC requires a sub-speciality consultation with a centre that performs the procedure. The conversation cannot happen at a centre that doesn’t offer it.
What to ask if you’re considering PIPAC
Six questions worth asking:
- Why is PIPAC being considered for my case specifically? The answer should reference the criteria above.
- What is the team’s annual PIPAC volume? Higher-volume centres have generally better outcomes.
- Is PIPAC being recommended alone or as part of a bidirectional approach with IV chemotherapy?
- What are realistic expectations for response, symptomatic improvement, histological response, survival extension?
- What is the written cost estimate per cycle and for the planned course?
- What is the recovery profile between cycles, and how does it interact with my other treatments?
These questions help distinguish a centre with deep PIPAC experience from one offering it as a peripheral service.
The bottom line
PIPAC is not a cure for recurrent ovarian cancer. It is a meaningful additional treatment option for a defined subset of patients, primarily those with peritoneal-predominant recurrent disease who remain otherwise fit. For those patients, PIPAC can extend survival, improve symptoms, and produce measurable disease response.
The most important fact is simply that PIPAC exists and is available in India in 2026 at a small number of centres including in Ahmedabad. The decision to use it should follow multidisciplinary review, but the option should be on the table.
If you are navigating recurrent ovarian cancer and PIPAC hasn’t been mentioned, it’s worth asking. The conversation may end with PIPAC not being appropriate for your case, but the question itself is reasonable.
About the author
This article was authored by Dr. Nishtha Tripathi Patel (MBBS, DGO, DNB, Fellowship in Gynaecological Oncology, ESGO-certified), an ESGO-certified gynaecological oncosurgeon in Ahmedabad with published academic work on PIPAC and bidirectional chemotherapy for advanced ovarian cancer. Reach her practice at +91 76988 00333.
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