Hyperthermic intraperitoneal chemotherapy in hepatocellular carcinoma with peritoneal metastasis or following spontaneous rupture

Peritoneal metastasis from hepatocellular carcinoma (HCC-PM) is uncommon and carries a poor prognosis. Hyperthermic intraperitoneal chemotherapy (HIPEC), usually combined with cytoreductive surgery (CRS), has been explored both for established HCC-PM and as a prophylactic/adjuvant strategy after spontaneously ruptured HCC (srHCC). This narrative review critically appraised clinical studies of therapeutic CRS+HIPEC for histopathologically confirmed HCC-PM and prophylactic/adjuvant HIPEC after srHCC. PubMed, Embase, Web of Science, Scopus, Cochrane Library, Google Scholar, reference lists, and ClinicalTrials.gov were searched from inception to 30 July 2026. Given marked heterogeneity in study design, patient selection, HIPEC regimens, and outcome reporting, evidence was synthesized narratively. The evidence base is limited and heterogeneous, consisting mainly of small retrospective cohorts, case series, and case reports. Available series indicate that CRS plus HIPEC is technically feasible in highly selected patients, and prolonged survival has been reported when preserved hepatic reserve and complete or near-complete cytoreduction are achievable. However, heterogeneous survival time origins, strong patient-selection effects, and the absence of adequate comparative evidence prevent determination of the independent contribution of HIPEC. In srHCC, the evidence for prophylactic/adjuvant HIPEC remains inconsistent, with some studies suggesting improved recurrence-related outcomes and survival, whereas others have shown no significant survival benefit. In addition, perioperative burden, length of stay, and costs may increase. CRS+HIPEC for HCC-PM and prophylactic/adjuvant HIPEC after srHCC remain investigational. Multidisciplinary assessment and transparent reporting of the factors influencing treatment selection are essential, and prospective multicenter studies with standardized endpoints are needed to define safety, efficacy, and optimal integration with contemporary systemic therapy.