Present and future of cytoreductive surgery and hyperthermic intrathoracic chemotherapy for pleural metastases: a narrative review

Our plain-English summary of Present and future of cytoreductive surgery and hyperthermic intrathoracic chemotherapy for pleural metastases: a narrative review, by A. Hajja, M. Atout, R. Turko, et al (European Respiratory Review, 2026).

The study

• Authors: A. Hajja, M. Atout, R. Turko, H. Syed, P. Duarte D'Ambrosio, R.M. Terra, A. Abdulhaq, M. Nardini, M.C. Ambrogi, M. Lucchi, H. Robaidi, W. Saleh, K. AlKattan, M. Migliore
• Journal: European Respiratory Review
• Published: 2026;35(179)
• Type of article: Review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Pleural malignancies pose a significant clinical challenge due to their poor prognosis and limited treatment options. Hyperthermic intrathoracic chemotherapy (HITHOC) is an emerging modality that has shown promise in treating primary pleural cancers when used with cytoreductive surgery (CRS), but its efficacy in treating pleural malignancies other than mesothelioma remains underexplored. This review aims to evaluate recent advancements in HITHOC use for nonmesothelioma pleural cancers and provide insights into its potential clinical applications.

Methods: A comprehensive Boolean search was conducted using PubMed/Medline and Google Scholar to identify relevant studies on the use of HITHOC for nonmesothelioma pleural cancers. Studies exclusively focused on pleural mesothelioma were excluded. Findings were summarised to address key questions regarding HITHOC's effectiveness, integration with other therapies and obstacles to its broader use.

Results: HITHOC, when combined with CRS, could prolong overall and progression-free survival and reduce complication and mortality rates in patients with advanced pleural cancers. Advances in chemo-immunotherapy, the evolution of minimally invasive techniques and the emergence of precision surgery hold significant promise in the treatment of pleural malignancies.

Conclusion: Given the challenges associated with HITHOC, including protocol variability and technical complexity, future research using larger, multinational datasets is essential to support its broader application and to identify patient-specific characteristics that enhance its efficacy in treating pleural cancers.

Copyright ©The authors 2026.

In plain English

This narrative review studied no new patients and did not examine asbestos exposure. The authors reviewed English-language articles on hyperthermic intrathoracic chemotherapy (HITHOC), heated chemotherapy given into the chest, usually after cytoreductive surgery (CRS) removing visible tumour. It covered non-mesothelioma pleural cancers, excluding mesothelioma-only studies. It discussed lung cancer, thymic tumours and cancers starting outside the chest, such as ovarian cancer and pseudomyxoma peritonei. One reviewed randomised trial in non-small cell lung cancer, without CRS, found median overall survival of 8 months (95% confidence interval 7.141 to 8.859) with HITHOC and 9 months (95% confidence interval 7.546 to 10.454) with talc pleurodesis, not significantly different. A German multicentre study of 58 patients with metastatic thymic tumours treated with CRS plus HITHOC reported 1-, 3- and 5-year survival of 95%, 83% and 77%. The review described kidney toxicity as one of the most frequently reported side effects. The authors concluded that CRS plus HITHOC is promising, but the evidence remains limited and largely retrospective. They called for larger multicentre prospective trials with standardised protocols.

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: Narrative review of published studies (no new patients studied)
• Who was studied: Published English-language studies on HITHOC for nonmesothelioma pleural cancers, found in PubMed/Medline and Google Scholar, with no year limit. Studies focused solely on pleural mesothelioma were excluded. The total number of included studies is not stated.
• Exposure: No asbestos or fiber exposure was studied. The review concerned a treatment: hyperthermic intrathoracic chemotherapy (commonly cisplatin), usually given after cytoreductive surgery, for lung, thymic, extrathoracic and rare primary pleural cancers other than mesothelioma.
• Main results:
  • In a randomised trial by Kleontas et al. in patients with non-small cell lung cancer and pleural effusion, CRS was not performed. Median overall survival was 8 months (95% CI 7.141–8.859) in the HITHOC group and 9 months (95% CI 7.546–10.454) in the talc pleurodesis group, with no significant difference between the two.
  • In a multicentre study by Ried et al. of 58 patients with metastatic thymic tumours treated with CRS plus HITHOC, 1-, 3- and 5-year survival rates were 95%, 83% and 77%. Five-year overall survival was 94% in thymoma patients and 41% in thymic carcinoma patients (p<0.001).
  • A German retrospective study (Hassan et al.) of CRS plus HITHOC in secondary pleural cancers from various primary tumours reported median overall survival of 39 months and median recurrence/progression-free survival of 14 months. It also reported a postoperative complication rate of 35% and in-hospital mortality of 10%.
  • A study by Yi et al. compared debulking surgery plus HITHOC (n=23) with debulking surgery alone (n=10) in lung adenocarcinoma with pleural dissemination. The overall survival difference was reported as significant (p=0.045).
  • The review described kidney toxicity as one of the most frequently reported adverse effects of HITHOC. A cited multicentre study of 700 patients given cisplatin-based HITHOC reported renal insufficiency in 41 patients, printed as 12%.
• The authors' conclusion: The authors concluded that HITHOC combined with CRS is an emerging, promising option for advanced secondary pleural cancers. They added that current evidence is limited and largely retrospective and that multicentre prospective trials are needed.
• Limitations the authors state:
  • Most lung cancer studies supporting CRS plus HITHOC are retrospective series or case reports in highly selected patients, which introduces potential selection bias.
  • Data on thymic cancers come mainly from small, single-centre cohorts or case series, and there are no randomised data.
  • The authors state that protocol heterogeneity and selection bias are major limitations of the evidence.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Intrathoracic, Chemotherapy, Prognosis, Mesothelioma, Pleural Mesothelioma, Progression-Free Survival, Immunotherapy.

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