Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up

Our plain-English summary of Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up, by P. Malekzadeh, M. Good, M.S. Hughes (International Journal of Hyperthermia, 2021).

The study

• Authors: P. Malekzadeh, M. Good, M.S. Hughes
• Journal: International Journal of Hyperthermia
• Published: 2021;38(1):326-331
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Malignant peritoneal mesothelioma (MPM) is a lethal cancer, with approximately 2% of diagnoses occurring in patients less than 40 years of age. The purpose of this study is to report the only long-term follow up and survival of pediatric patients with MPM after multi-modality therapy including cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods: We retrospectively investigated a prospectively maintained database including patients <21 years old who underwent CRS and HIPEC from 1994 through 2014. Follow-up information was available through 2019 and is included in this report.

Results: Seven young patients underwent CRS and HIPEC. Final histology was epithelioid in all patients. Three patients had received neo-adjuvant systemic chemotherapy. At the time of the operation Peritoneal Cancer Index ranged from 6 to 25. Completeness of cytoreduction score after CRS was 0 in 4 patients, 1 in two patients, and 2 in one patient. Post-operative complications included acute kidney injury (n = 1), hyperbilirubinemia (n = 1), bilateral pleural effusions (n = 1) and pneumothorax requiring chest tube placement (n = 1). At last available follow-up, 71% of patients (n = 5) were alive with minimal or no evaluable disease. The remaining two patients had passed away from their disease at 14 and 26 months, respectively, following CRS and HIPEC. Overall survival ranged between 14 and 281 months.

Conclusion: Our surgical experience shows that CRS and HIPEC is a feasible and safe treatment option in pediatric patients, potentially improving overall survival.

In plain English

This was a report on seven young patients, aged 12 to 18 (median 16), with malignant peritoneal mesothelioma treated at the National Cancer Institute's Surgery Branch. The authors looked back at a database of 109 patients with this cancer who had cytoreductive surgery, which removes as much visible tumor as possible, followed by heated chemotherapy circulated through the abdomen (HIPEC). They selected those under 21 at treatment, and all seven received HIPEC with cisplatin. All seven tumors were epithelioid. The article does not report asbestos or any other exposure. No patient died from the operation. Complications included kidney injury, raised bilirubin, fluid around the lungs, and a collapsed lung needing a chest tube. Six of the seven patients had their symptoms resolve. At last follow-up five were alive and two had died of their disease. The longest survival was 281 months. The authors concluded that combined treatment including this surgery and HIPEC can perhaps improve long-term outcomes. They noted the small number of patients, the look-back design, and that young age itself may have helped survival. Some figures differ between the text and the tables.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of a prospectively maintained institutional database (single-institution case series of seven patients)
• Who was studied: Seven patients under 21 years of age at treatment (median age 16, range 12 to 18; 4 female, 3 male), drawn from 109 patients with histologically proven malignant peritoneal mesothelioma who had CRS and HIPEC at the NCI Surgery Branch between 1994 and 2011, with follow-up through 2019
• Exposure: The article does not report asbestos or other fiber exposure. The study examined treatment of the seven patients: cytoreductive surgery followed by HIPEC for 90 minutes with cisplatin at 250 mg/m2, plus perioperative sodium thiosulfate. Three patients (1, 4, 6) also received early postoperative intraperitoneal paclitaxel and 5-FU.
• Main results:
  • Tumor histology was epithelioid in all seven patients
  • Peritoneal Cancer Index at operation ranged from 6 to 25. Completeness of cytoreduction was 0 (no gross residual disease) in 4 patients and 1 to 2 in 3 patients.
  • There were no operative deaths. Reported post-operative adverse events included acute kidney injury, hyperbilirubinemia, bilateral pleural effusions and pneumothorax requiring a chest tube (one patient each). Two patients had anemia and coagulopathy needing blood products. The most severe HIPEC-associated toxicity was Grade 3 renal insufficiency, which resolved with conservative management.
  • Average hospital stay was 18.6 days, with a range of 13 to 24 days
  • Six of the seven patients had their symptoms resolve, including complete resolution of ascites in all three patients who had ascites before surgery
  • At last follow-up, 5 of 7 patients (71%) were alive. Two patients died of their disease, at 14 months and at 26 months (27 months in the text) after CRS and HIPEC.
  • One patient (patient 2) had repeat CRS and HIPEC for recurrence 120 months after the first operation and was alive with disease 281 months after initial treatment
  • Five of the seven patients received second- or third-line treatments at the NCI at some point
• The authors' conclusion: The authors concluded that multi-modality therapy including CRS and HIPEC can perhaps improve long-term outcomes in these young patients. They also concluded that it is reasonable to keep offering it to reduce disease burden, improve symptoms and possibly extend survival until better therapies exist.
• Limitations the authors state:
  • Retrospective design with its inherent biases, and a small sample size
  • Postoperative intraperitoneal chemotherapy was not given to all patients and may have affected outcomes
  • Ki-67 expression was not measured
  • Younger age alone may have contributed to the survival seen
  • No definitive conclusion could be drawn on the role of completeness of cytoreduction because of the small number of patients
  • The absence of treatment-related deaths may reflect the small sample size

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Cisplatin, Peritoneal Mesothelioma, Histology, Epithelioid, Chemotherapy, Peritoneal Cancer Index (PCI).

Related studies

• Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin — P. Owusu-Agyemang, R. Arunkumar, et al. (2012)
• Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for disseminated intra-abdominal malignancies in children-a single-institution experience — O. Zmora, A. Hayes-Jordan, et al. (2018)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• Repeat cytoreductive surgery and heated intraperitoneal chemotherapy may offer survival benefit for intraperitoneal mesothelioma: a single institution experience — J. Wong, A.L. Koch, et al. (2014)

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