Peritoneal Metastases (Carcinomatosis) Treatment in Germany

Peritoneal metastases have become a high-priority topic in cancer care because outcomes can change a lot depending on where and how a patient is treated.^[1] In routine settings, prognosis is often limited. German clinical trial documentation cites an average life expectancy of 3 months when no active anti-cancer treatment is provided.^[2][4]

Even with modern systemic therapy, results can remain modest.^[3] Therefore, we explore here what the German healthcare system can offer for the treatment of peritoneal metastases.

This article is for international patients and families considering treatment in Germany, and for referring clinicians seeking a clear, practical overview of what specialist centers typically offer and how they determine who may benefit.

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Understanding Peritoneal Carcinomatosis

Peritoneal carcinomatosis is a type of cancer spread characterized by tumor deposits that develop on the thin lining inside the abdomen, known as the peritoneum.^[5] In clinical writing, this condition is often referred to as peritoneal metastases, particularly when the cancer has spread from another primary tumor.^[6]

This spread rarely remains flat. It can develop into tiny nodules, plaques, or larger masses, and it often affects the omentum, the apron of fat that hangs over the bowel. This is why scans and surgical notes often describe peritoneal and omental metastases together.^[7][8] The omentum is a well-known "landing zone" for tumor cells within the abdominal cavity, which helps explain its frequent involvement.^[7][9]

A common turning point is the accumulation of fluid in the abdomen, known as malignant ascites. It’s strongly associated with peritoneal tumor involvement and is often what finally makes the disease impossible to ignore (bloating, early satiety, tight abdomen, shortness of breath).^[10] Among all causes of ascites, malignant ascites accounts for around 10% of cases.^[11]

Primary Metastases Sources

In most patients, peritoneal involvement is secondary, meaning that the cancer originates in another area and then spreads to the abdominal cavity.^[12] The most common types of tumors that contribute to this spread are those located near the peritoneum or that release cells into the peritoneal cavity. According to major clinical reviews, the most frequently reported origins of these tumors include ovarian, colorectal, gastric, pancreatic, and uterine (endometrial) cancers.^[7]

A special category is appendiceal mucinous tumors, which can disseminate mucin-producing cells throughout the abdomen (often referred to as pseudomyxoma peritonei in imaging and surgical oncology).^[13] This is one reason German and international centers pay close attention to tumor biology, not just “where it started.”

More rarely, peritoneal carcinomatosis can come from cancers outside the abdomen. About 9% of patients with peritoneal malignant involvement had an extra-abdominal primary, most commonly breast or lung cancer (with melanoma also represented).^[14] This matters because the treatment logic can change depending on the origin.

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Treatment Modalities Available in Germany

Germany offers structured, specialist-led care for the treatment of peritoneal metastases, some of which are not widely available elsewhere. Below, we outline the available modalities used in university hospitals and specialized clinics and what they typically mean for patients in practice.

Cytoreductive Surgery & HIPEC

Many specialist centers approach selected cases of peritoneal metastases with a two-step strategy, often summarized as “HIPEC peritoneal carcinomatosis in Germany”.

First, doctors perform cytoreductive surgery (CRS) to remove all visible tumor deposits from the peritoneal surfaces (and, if needed, affected organs). Then, the hyperthermic intraperitoneal chemotherapy, so-called HIPEC procedure, delivers concentrated chemotherapy medications directly inside the abdominal cavity while the patient is still in the operating room.^[15]

The logic is as follows: surgery targets what can be seen and removed, and HIPEC targets what may remain at a microscopic level.

How HIPEC Works

Hyperthermic intraperitoneal chemotherapy is essentially a controlled, closed-loop “wash” of warmed chemotherapy circulated through the abdomen. The solution is typically heated to about 41–43°C, because heat can enhance drug effectiveness and improve tissue penetration compared with room-temperature perfusion.^[15][16]

The key advantage is local intensity. Intra-abdominal chemotherapy allows high drug exposure on the peritoneal surfaces with lower whole-body exposure than standard IV delivery.^[17]

Here’s what the HIPEC part typically looks like in practice:

• Catheters & Temperature Probes are Placed. Surgeons position the inflow and outflow tubes in the abdomen and insert probes to monitor temperature during circulation.
• Close-Up. The abdomen is temporarily closed or covered. Many German centers seal the cavity (or use a special covering) to create a controlled circuit for the perfusion.
• Circulation Starts. A heated chemotherapy solution is continuously pumped, circulated, and drawn back through a closed loop. Some protocols use 3–6 liters of perfusate to fill and circulate through the cavity.
• Duration. The “wash” runs for a set time, often 60–90 minutes. This window is commonly used to maximize surface contact and exposure while limiting systemic toxicity.
• Drain, rinse, & close. At the end, the solution is drained, the cavity may be rinsed, catheters are removed, and the final closure (and any remaining reconstruction) is completed.

In practice, hospitals may use an open or closed technique for circulation, but the core goal is the same: uniform distribution of heat and drugs across the abdominal cavity after the tumor has been surgically cleared.^[15][18]

Patient Selection

Not all patients benefit from CRS + HIPEC. The decision-making process begins with tumor burden, measured using the Peritoneal Cancer Index (PCI) score.^[19] PCI divides the abdomen into regions, scores tumor size in each region, and sums the scores to produce a total score of 0 to 39. A lower score generally indicates a narrower spread and a greater likelihood of complete clearance.^[19][20]

The second make-or-break factor is whether the surgeon can achieve complete cytoreduction.

• CC-0 means no visible tumor remains.^[19]
• CC-1 indicates only tiny residual nodules remain (commonly defined as ≤2.5 mm), which are potentially treatable with heated intraperitoneal drug exposure.^[19]

This is why German programs emphasize strict selection and experienced teams. Outcomes for peritoneal metastases treatment are strongly linked to PCI and to the ability to achieve CC-0/CC-1; Germany maintains national experience with CRS and HIPEC through registry-based analyses.^[20][21]

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Pressurized Intraperitoneal Aerosol Chemotherapy

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive way to deliver chemotherapy directly onto the peritoneum during laparoscopy.^[22] Instead of filling the abdomen with a liquid chemo bath (as in HIPEC), PIPAC turns the drug into a fine aerosol and applies it under pressure inside the abdominal cavity. The pressure facilitates the aerosol's spread across peritoneal surfaces and enhances contact with tumor nodules in peritoneal metastases.^[23]

This is the key difference from HIPEC. HIPEC is typically a single, major operation performed immediately after cytoreductive surgery, using heated, circulating fluid. PIPAC is usually a short laparoscopic procedure, often repeated every 6–8 weeks, and can be used when a full CRS with HIPEC is not possible.^[24]

Benefits of PIPAC for Inoperable Patients

For patients with peritoneal metastases who are not candidates for major cytoreductive surgery, PIPAC is often discussed as a pragmatic option.^[23] That is because it is repeatable and comparatively low-burden.

• Short Procedure, Short Stay. A large international database report showed a median hospital stay of 2 days.^[25]
• Feasible Even in Advanced Cases. The overall non-access rate was 3.5% (meaning the laparoscopy could not be safely performed or completed).^[25]
• Symptom Focus Matters. Many patients with peritoneal spread struggle with malignant ascites. Evidence summaries note that ascites control is one of the most realistic clinical goals of PIPAC in routine practice.^[26]

In real-world workflows, the PIPAC strategy also provides the team with something HIPEC typically does not: repeatable checkpoints. Each session can include visual reassessment, ascites evaluation, and biopsies to document response over time.^[23]

In a small German series, repeated PIPAC was followed by secondary CRS/HIPEC in selected responders.^[27]

The German Origin

PIPAC is strongly associated with German surgical oncology. The method was developed in Germany by the team around Prof. Marc André Reymond and colleagues in the early 2010s.^[28][29]

The German Clinical Trials Register documents that PIPAC has been routinely performed since 2015 in individual therapeutic trials, noting the first PIPAC treatment at Marien Hospital Herne.^[30]

In July 2016, Prof. Reymond moved to University Hospital Tübingen to lead a dedicated national program focused on pleural and peritoneal surface disease.^[31] The site became a visible reference point for training and structured implementation.

Germany’s experience is also measurable at a national level. Nationwide hospital data is captured for routine use. For instance, in 2019, 534 patients received PIPAC in German hospitals, with 0% in-hospital mortality and only 8% postoperative complications.^[32] This scale matters because it supports standardization and makes Germany one of the most “data-rich” settings for PIPAC in peritoneal metastases.

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Pressurized Intraperitoneal Aerosol Chemotherapy with Hyperthermia

Standard PIPAC is usually normothermic. This means chemotherapy is aerosolized during laparoscopy and applied under pressure, but neither medications nor the abdominal cavity are heated.

The “hyperthermia” version maintains the abdominal cavity (or the patient) within a therapeutic temperature range during aerosol delivery.^[33] The idea is to combine two effects at once: the pressure and aerosol physics of PIPAC with the heat-enhanced cytotoxicity known from regional hyperthermia concepts.^[34]

In practice, this approach is particularly discussed for diffuse disease patterns, such as omental peritoneal metastases, where uniform surface contact is difficult to achieve with systemic therapy alone. Hyperthermia is intended to enhance local drug activity, whereas the aerosol is intended to achieve broad spatial coverage across the peritoneal and omental surfaces.^[34]

The key takeaway is that PIPAC with hyperthermia remains more experimental than standard PIPAC.^[33] You’ll mostly encounter it in specialized programs and study-like protocols, which are positioned as attempts to improve local control in challenging settings, such as advanced peritoneal metastases.

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Electrostatic PIPAC

Electrostatic PIPAC (often abbreviated as ePIPAC) is a technical upgrade of standard PIPAC for the treatment of peritoneal metastases. The main difference is in how chemotherapy is delivered. After the drug is aerosolized into the abdomen, an electrostatic field is applied. This field actively attracts the droplets to the peritoneal surfaces.^[35] Therefore, the method does not rely primarily on passive settling and airflow.

Why does that matter? Standard PIPAC can produce “gravity effects” and uneven distribution. More drugs in dependent areas, fewer in others. ePIPAC aims to reduce uneven drug distribution and enhance its coating of the abdominal lining.^[36]

Mechanistically, the technique uses an intra-abdominal electrode (often described as an “ion wand”) to charge the aerosol and promote electrostatic precipitation onto tissue.^[35]

The first human applications were published by the German-led development group associated with the PIPAC innovation. They reported on the technical feasibility and tolerability of the procedure and advocated further prospective studies.^[35] This positions ePIPAC as a promising method for improving local delivery in selected patients with peritoneal metastases.

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Isolated Hypoxic Abdominal Perfusion

Isolated hypoxic abdominal perfusion (IHAP) is a locoregional chemotherapy technique used in Germany.^[37] It treats advanced abdominal spread, including peritoneal and omental metastases.^[38] This method is employed when standard systemic options are limited or no longer effective.

The treatment approach is closely associated with Prof. Dr. Karl R. Aigner and the broader “regional chemotherapy” approach, which aims to achieve very high drug exposure in the abdomen while keeping whole-body toxicity comparatively low.^[37]

The procedure is typically performed using femoral access. Special balloon catheters are advanced into the aorta and vena cava, where they are positioned to temporarily isolate blood flow to the abdomen. In the standard workflow, chemotherapy is infused first, followed by balloon inflation to create a short stop-flow phase that produces very high local drug concentrations. After this phase, an isolated hypoxic perfusion phase is initiated through the catheter's side holes. Finally, chemofiltration is performed to reduce the systemic drug load once normal circulation is restored.^[39]

The technique aims to establish low-oxygen conditions in the isolated area, as certain agents used in these protocols exhibit increased cytotoxicity under hypoxic conditions. By creating this low-oxygen atmosphere, the effectiveness of these agents can be maximized.^[37] To further enhance safety and minimize side effects, chemofiltration is incorporated into the process, ensuring a more targeted and beneficial treatment.^[40]

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FAPI-Targeted Radioligand Therapy

Metastatic cancer spreading to the peritoneum requires emerging treatment options. Therefore, innovations don't stop. Below, we explain how FAPI-targeted radioligand therapy is being explored for advanced metastatic patterns, including peritoneal disease, where standard systemic options may be limited.

Understanding Targeted FAPI Radiation Concept

FAPI-targeted radioligand therapy (often abbreviated as FAPI-RLT) is a theranostic approach used in cancer treatment that targets fibroblast activation protein (FAP).^[41] FAP is a marker that is frequently found in cancer-associated fibroblasts within the tumor stroma of various solid tumors and complex metastatic patterns (including cases with peritoneal involvement).^[42]

The term “FAPI” refers to the small molecule that binds to FAP, while “radioligand therapy” involves a therapeutic radionuclide, typically beta-emitters like yttrium-90 or lutetium-177, which is attached to that molecule.^[43] This combination allows radiation to be delivered precisely to the sites where the tracer accumulates.

Patient selection often begins with FAPI-PET/CT (e.g., 68Ga-FAPI tracers). If tumors show strong uptake relative to background, a center may consider therapy.^[41]

German Role

Germany is one of the key “origin points” for the FAPI platform. Much of the early tracer development and clinical translation is linked to University Hospital Heidelberg and the German Cancer Research Center (DKFZ), which helped advance FAPI from imaging to therapeutic concepts.^[43]

It is usually conducted within a clinical study framework because the evidence base is still emerging and disease-specific standards are not yet widely established.^[44]

Clinical therapy experience has also been reported by major German nuclear medicine networks, such as University Hospital Essen, in early FAPI-RLT publications.^[45]

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Neoadjuvant Intraperitoneal & Systemic Chemotherapy

This concept is best understood as a “downstaging attempt” for certain patients with early peritoneal carcinomatosis. Systemic chemotherapy treats microscopic disease throughout the body, whereas intraperitoneal chemotherapy targets tumor cells directly.^[46]

In Germany, this approach is implemented through NIPS (neoadjuvant intraperitoneal systemic therapy). A subcutaneous abdominal port delivers chemotherapy into the peritoneal cavity alongside intravenous treatment.^[47]

Intraperitoneal CAR-T Cell Therapy

Intraperitoneal CAR-T is an immunotherapy approach for the treatment of peritoneal carcinomatosis that aims to address a practical problem. Engineered T-cells delivered by vein often struggle to reach, survive, and function within the peritoneal cavity. Instead, CAR-T cells are infused directly into the abdomen to achieve higher local cell density at tumor deposits. This also provides more direct physical contact with peritoneal metastases, thereby improving efficacy.^[48]

Peritoneal tumors are located on surfaces and within fluid spaces, which makes regional delivery an appealing option. A 2025 study, along with a phase I trial, demonstrated that intraperitoneal CAR-T therapy produced greater antitumor activity and longer persistence than lower-dose intravenous dosing in models of peritoneal carcinomatosis.^[49][50] This supports the fundamental idea of "placing the cells where the disease is located."

Practical Application for Malignant Peritoneal Disease

The concept is still the same CAR-T you may know from blood cancers (collect T-cells, engineer them to recognize a target, expand them), but the delivery route is regional.^[51] Patients may receive lymphodepletion first (a short course of chemotherapy to kill T cells), and then a single or repeated intraperitoneal infusion via laparoscopy or an intraperitoneal access system, depending on the protocol.^[52][50]

It is worth noting that intraperitoneal CAR-T therapy for peritoneal metastases remains investigational.^[53] It’s mainly available via early-phase trials and early individual patient selection.

The studies that are currently in place actively explore the treatment for CEA-expressing adenocarcinoma peritoneal metastases, gastric cancer with peritoneal metastasis, and gastroesophageal cancer peritoneal carcinomatosis as practical examples.^[50][54][55]

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Catumaxomab for Malignant Ascites

Catumaxomab is a hybrid monoclonal antibody used to manage malignant ascites (which is common for peritoneal malignancy) when other systemic cancer treatments are no longer viable. It is delivered locally as an immune-activating therapy.^[56]

In the EU, it is known as Korjuny and is authorized for adults with EpCAM-positive carcinomas and malignant ascites.^[56] The treatment is administered intraperitoneally, meaning it is injected directly into the abdominal cavity.

This therapy differs from simple fluid drainage because its goal is to slow the rate at which fluid re-accumulates. It also aims to reduce the frequency of paracentesis procedures.^[57]

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Top Hospitals & Specialists for Peritoneal Treatment in Germany

Look for certified surgical oncology centers and high-volume HIPEC centers in Germany that provide advanced peritoneal metastases treatment solutions. These hospitals often participate in clinical trials and explore novel treatment options. Additionally, they are part of multidisciplinary tumor boards that collaborate to make informed decisions on complex cases.

For patients relying on individual specialist opinions, we present the doctors who specialize in treating peritoneal cancer throughout Germany. These specialists are often pioneers, implementing and practising the latest treatment options. Check the profiles of these doctors to seek a second opinion and plan a therapy that best fits your individual case.

Success Rates & Clinical Outcomes in German Centers

Outcomes for peritoneal metastases in Germany differ significantly depending on the type of primary tumor, the tumor load (PCI), and the feasibility of achieving complete cytoreduction.

The studies and results presented below reflect the types of data typically reported by German centers and registries. These figures serve as a guide rather than a guarantee, as patient selection strongly influences outcomes.

Comparative Results

Treatment option	German-led data
Cytoreductive Surgery & HIPEC	National gastric-cancer registry report: complete cytoreduction in 71.6%, complications in 17%; median survival about 13 months. The patients achived 5-year survival rate is 6%.[21] The Regensburg Tumor Center cancer registry indicates a median survival of 41.6 months with CRS+HIPEC compared to 24.0 months for surgery plus chemotherapy, and 14.1 months for chemotherapy alone for isolated colorectal peritoneal metastases.[58] University Hospital Tübingen is showing results for recurrent epithelial ovarian cancer with peritoneal metastases. The data indicate complete cytoreduction with HIPEC in 69% and a cumulative morbidity of 42%. Survival separated clearly by completeness: median survival 35 months (CC-0/1) vs 14 months (CC-2/3).[59] University Hospital Regensburg highlights data about pseudomyxoma peritonei. Reported median survival was 51 months overall; if complete cytoreduction was achieved, mean survival increased to 73 months vs 26 months with incomplete resection. They also report a 5-year survival of 80% after complete cytoreduction.[60]
PIPAC	A German single-center chemorefractory gastric cancer cohort showed the follwing results: 24% of patients had metastatic regression, 44% had stable disease. Median survival was 181 days from first PIPAC.[32]
PIPAC with Hyperthermia	Whole-body hyperthermia PIPAC (WBH-PIPAC) data from Clinic Dortmund showed no grade III–V complications; procedure-related complications 9/50 (7 grade I, 2 grade II).[61]
ePIPAC	European multicenter clinical experience reported postoperative complications in 4.7% of cases.[62]
Isolated Hypoxic Abdominal Perfusion	Data from the Oncological Clinic Medias Burghausen study for platinum-refractory ovarian cancer patients showed an imaging response rate of 54.1%, with ascites resolving in 30% and reduced in 43%; median survival was 10-12 months.[37] A colorectal study from University Hospital Charité Berlin reported an overall response rate of 64.7%, a median survival of 15.5 months, and no perioperative deaths.[63]
FAPI-Targeted Radioligand Therapy	Data for solid tumors from University Hospital Essen show disease control of 38%, post-treatment lesion uptake of 78%, and radiographic disease control of 50%.[45][65]
Neoadjuvant Intraperitoneal & Systemic Chemotherapy	Patients who received an intraperitoneal paclitaxel combination lived a median of approximately 19.4 months, compared with 13.9 months in the control group (approximately a 5–6-month improvement).[64]
Intraperitoneal CAR-T Cell Therapy	A 2025 preclinical study shows that intraperitoneal CAR-T therapy improves survival compared with intravenous delivery in peritoneal carcinomatosis models.[49]
Catumaxomab for Malignant Ascites	Randomized trial puncture-free survival 46 vs 11 days (catumaxomab vs control), and time to next paracentesis 77 vs 13 days. This indicates that a 4-fold improvement in punctuality is required for malignant ascites. and an almost 6-fold reduction in the need for paracentesis.[57]

Cost of Peritoneal Metastases Treatment in Germany

Treatment costs for peritoneal metastases in Germany can vary widely depending on the approach, disease-specific factors, hospital type, and length of stay. Review the potential costs before planning treatment in Germany.

Average Cost Breakdown

In this section, we outline typical cost ranges and the quotes international patients can expect for each treatment type used for cancer metastasis to the peritoneum.

Treatment option	Price ranges
Cytoreductive Surgery & HIPEC	From 65,000 €
PIPAC	30,000-45,000 €
PIPAC with Hyperthermia	34,000-50,000 €
ePIPAC	35,000-52,000 €
Isolated Hypoxic Abdominal Perfusion	From 33,500 €
FAPI-Targeted Radioligand Therapy	From 25,000 €
Neoadjuvant Intraperitoneal & Systemic Chemotherapy	6,000-23,000 €
Intraperitoneal CAR-T Cell Therapy	From 450,000 €
Catumaxomab for Malignant Ascites	From 15,000 €

Factors Influencing Treatment Price

Treatment prices in Germany mainly depend on the extent of the disease and the complexity of the planned intervention.^[66] When peritoneal spread is limited, procedures can be shorter, and recovery tends to be simpler. When disease is widespread, operations take longer, more steps and sessions may be required, and overall hospital resource use increases, so the quote rises.

Length of stay is one of the biggest cost drivers. A straightforward course on a regular ward costs far less than a prolonged admission, and any need for ICU monitoring can change the final amount quickly.^[67] The same logic applies to repeatable treatments: if a method is planned as several sessions or multiple cycles, the total cost is usually the per-session price multiplied by the number of sessions, plus additional checks in between.

Diagnostics and reassessments also affect the price. Some quotes include only the procedure itself, while others bundle imaging, laparoscopy, biopsies, pathology, and molecular testing. Complications or unexpected findings can trigger additional procedures, longer hospitalization, transfusions, or extended monitoring, which is why hospitals often provide a range rather than a single fixed price.^[66]

Finally, the hospital setting and “unplanned extras” matter. University centers, some private clinics, and high-volume programs may charge higher base tariffs, and international patient services (coordination, interpreters, case management) may incur additional fees.

Why Germany is a Global Leader?

Germany stands out in the care of peritoneal metastases for combining rigorous quality control, national data capture, and genuine innovation.^[68] Therefore, patients aren’t just offered “options,” they’re offered structured decision-making and measurable outcomes.

Check what can make peritoneal carcinomatosis treatment in Germany superior to other destinations below:

• Evidence-Based Standards. German cancer guidelines (S3) are developed through the German Guideline Program in Oncology under the umbrella of the AWMF, the German Cancer Society, and the German Cancer Aid. This promotes consistent, evidence-based practices rather than doctor-to-doctor variability.^[69]
• Certified Surgical Oncology Centers. Germany’s certification ecosystem (including organ cancer centers and comprehensive cancer centers) is designed around measurable quality indicators and continuous auditing.^[70] One practical result is that multidisciplinary tumor board decision-making is a formal, monitored requirement in certified settings.^[68] This matters for complex peritoneal cases where surgery, medical oncology, imaging, pathology, and supportive care must align.
• Transparent Performance Data. For high-stakes procedures like CRS+HIPEC, Germany doesn’t rely only on single-center “best case” stories. National registry analyses from the German Society for General and Visceral Surgery (DGAV) registry report real-world morbidity/mortality across many hospitals, supporting benchmarking and safer implementation.^[71]
• Pioneering Inventions. PIPAC is a German-born technology. The development is closely linked to German surgical oncology groups. That “pioneering” role is why Germany accumulated early expertise and helped define how PIPAC should be delivered safely and reproducibly.^[72]
• Strong Translational Pipeline. Germany is also a key origin point for emerging theranostic approaches (e.g., FAPI imaging/therapy), driven by major academic ecosystems. This shortens the path from lab concept to structured clinical use.^[73]
• Wide Provider Landscape. The country offers a range of medical providers and individual doctors practising peritoneal cancer spread surgeries. The German Cancer Society lists more than 2,000 Certified Cancer Centres, multiple university settings, and various private clinics that are eligible for high-quality peritoneal carcinomatosis care.^[74]

Frequently Asked Questions (FAQ)

References

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