Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience

Our plain-English summary of Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience, by M. Ried, T. Potzger, N. Braune, et al (European Journal of Cardio-thoracic Surgery, 2013).

The study

• Authors: M. Ried, T. Potzger, N. Braune, R. Neu, Y. Zausig, B. Schalke, C. Diez, H.S. Hofmann
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2013;43(4):801-7
• Cited by: 71 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: A combination of cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) was performed for the treatment of primary and secondary pleural malignancies. We describe the perioperative management and our clinical experience.

Methods: Between September 2008 and August 2011, eight patients with pleural manifestation of thymoma (Masaoka stage IVa) and eight patients with malignant pleural mesothelioma (MPM) were prospectively enrolled. Postoperative morbidity, recurrence and survival rates were analysed.

Results: All the patients received multimodality therapy, including chemotherapy, radiation and surgical resection (pleurectomy/decortication) followed by the HITHOC procedure. Chemotherapy perfusion was performed with cisplatin (100-150 mg/m(2)) at 42°C for 1 h. Severe chemotherapy-related complications were not observed. Reoperation was necessary in two patients. There was no 30-day mortality. The median stay on the intensive care unit was 1 day, and the median duration of hospitalization was 15 days. Pleural recurrence of thymoma was evident in one thymoma patient 6 months after HITHOC. At mean follow-up of 22 months, seven thymoma patients (7/8; 88%) are alive without recurrence. Tumour progression was present in six mesothelioma patients (6/8; 75%). Four patients (50%) with MPM are alive, including two with no evidence of mesothelioma, and the median survival is 18 months.

Conclusions: Cytoreductive surgery in combination with HITHOC can be performed with acceptable morbidity and mortality rates in selected patients. Patients should be evaluated by an interdisciplinary team to determine their eligibility for this therapeutic alternative. Early clinical results may encourage the use of this surgical option to provide better local tumour control in a multimodality treatment setting.

In plain English

This observational, prospective study took place at a single hospital in Regensburg, Germany. Between September 2008 and August 2011 it enrolled 16 patients judged suitable for surgery aimed at cure: eight with malignant pleural mesothelioma and eight with thymoma that had spread to the pleura (Masaoka stage IVa). Asbestos exposure was reported in four of the mesothelioma patients. Every patient had surgery to strip the pleura and remove visible tumour (pleurectomy/decortication). This was followed immediately by flushing the chest cavity with heated cisplatin chemotherapy at 42°C for one hour, as part of wider treatment. No patient died in hospital or within 30 days. Two patients needed further surgery for complications. No severe chemotherapy-related complications, including kidney damage, were observed. Among the mesothelioma patients, four of eight were alive after a mean follow-up of 17.4 months, and median survival was 18 months. Six of eight had tumour progression or recurrence. The authors reported seven of eight thymoma patients alive without recurrence. They concluded the approach is feasible with acceptable complication and death rates. They noted the small sample, lack of randomization, possible selection bias and short follow-up.

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: Observational, prospective, single-centre feasibility study with no comparison group
• Who was studied: 16 patients (13 male, 3 female; mean age 56 years) at the University Medical Center Regensburg, Germany, enrolled September 2008 to August 2011. Eight had malignant pleural mesothelioma (7 epithelial, 1 biphasic-epithelial) and eight had pleural metastases of thymoma (Masaoka stage IVa). Only patients whose tumour was judged almost certainly completely resectable were included.
• Exposure: The study examined a treatment rather than an exposure: pleurectomy/decortication followed by hyperthermic intrathoracic chemotherapy perfusion (HITHOC) with cisplatin. Asbestos exposure was reported in four of the eight mesothelioma patients. No fiber types or exposure details were given.
• Main results:
  • All 16 patients had chemotherapy perfusion with cisplatin (100–150 mg/m2) at 42°C for 1 hour after surgery. 14 patients received 100 mg/m2 and the last two received 150 mg/m2.
  • No patient in the series died in hospital or within 30 days of the operation.
  • Two patients had severe complications that needed further surgery. One mesothelioma patient had a ruptured diaphragm. One thymoma patient needed emergency removal of the lung (pneumonectomy) for respiratory insufficiency, sepsis and haemothorax. A third patient, with thymoma, had a vein thrombosis.
  • No severe chemotherapy-related complications were observed in the 16 patients, including no kidney impairment from cisplatin.
  • For all 16 patients, the median intensive care stay was 1 day (range 1–13 days) and the median hospital stay was 15 days (range 8–63 days).
  • Mesothelioma patients: after a mean follow-up of 17.4 months (range 13–28 months), 4 of 8 (50%) were alive, and overall median survival was 18 months.
  • Mesothelioma patients: 6 of 8 (75%) had tumour progression or recurrence, two of whom were still alive at the end of the analysis. In every case the recurrence first appeared on the operated side of the chest. Median time to recurrence was 4.5 months (range 3–16 months).
  • Thymoma patients: the authors reported 7 of 8 (88%) alive without evidence of recurrence, with a mean follow-up of 22 months (range 7–35 months; median survival 23 months). One thymoma patient had pleural recurrence and died 35 months after surgery. Another had a recurrence in the mediastinum at 13 months that was removed surgically.
• The authors' conclusion: The authors concluded that pleurectomy/decortication combined with HITHOC is feasible and can be done with acceptable rates of complications and death in patients with pleural spread of thymoma and malignant pleural mesothelioma. They called for future multicentre studies.
• Limitations the authors state:
  • Small sample size, no randomization, possible patient selection bias, and fairly short follow-up, especially for the thymoma patients.
  • Follow-up of the thymoma patients may be too short to give reliable data on long-term survival.

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, Intrathoracic, Chemotherapy, Pleural Mesothelioma, Multimodal Therapy, Surgical Resection, Pleurectomy/Decortication (P/D), Cisplatin.

Related studies

• Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies — M. Ried, T. Potzger, et al. (2013)
• Cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy in patients with malignant pleural mesothelioma or pleural metastases of thymoma — E. de Bree, S. van Ruth, et al. (2002)
• Pharmacokinetics of doxorubicin and cisplatin used in intraoperative hyperthermic intrathoracic chemotherapy after cytoreductive surgery for malignant pleural mesothelioma and pleural thymoma — S. van Ruth, O. van Tellingen, et al. (2003)
• 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 and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience — M. Migliore, D. Calvo, et al. (2015)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal metastases — T.C. Chua, L.E. Quinn, et al. (2013)

Browse more research in European Journal of Cardio-thoracic Surgery, or return to medical research.