Preventing recurrence of diffuse malignant peritoneal mesothelioma

Our plain-English summary of Preventing recurrence of diffuse malignant peritoneal mesothelioma, by J.C. Leinwand, J.A. Chabot, M.D. Kluger (Expert Review of Anticancer Therapy, 2016).

The study

• Authors: J.C. Leinwand, J.A. Chabot, M.D. Kluger
• Journal: Expert Review of Anticancer Therapy
• Published: 2016;16(9):989-95
• Type of article: Review
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Diffuse malignant peritoneal mesothelioma (DMPM) is an aggressive malignancy with a poor prognosis when treated with systemic therapy. Cytoreductive surgery (CRS) with intraperitoneal chemotherapy (IPC) is considered the best therapy in DMPM, but a high risk of locoregional recurrence remains.

Areas Covered: This review describes patient selection and operative goals with CRS and IPC, the reported outcomes with this approach, and the data supporting platinum-based IPC. We assess the pharmacokinetics supporting the use of dwell IPC. We outline clinical, imaging and laboratory surveillance for recurrence. In addition, we highlight the role of re-operation, both as a planned second procedure and in the context of disease recurrence. Literature review was performed via Medline search. Expert commentary: CRS/IPC offers survival benefit in selected patients with DMPM, but given the high rate of recurrence, close surveillance is needed post-operatively. Strategies to prevent and treat recurrent disease include dwell IPC and second CRS/IPC.

In plain English

This article was a review of published research on preventing and treating the return of diffuse malignant peritoneal mesothelioma (DMPM), a mesothelioma of the peritoneum (the lining of the abdomen). The authors were from the Department of Surgery at Columbia University Medical Center, and they searched the literature through Medline. The article does not discuss asbestos. The authors described reports that surgery to remove visible tumor (cytoreductive surgery, CRS) combined with chemotherapy placed directly into the abdomen (intraperitoneal chemotherapy, IPC) was followed by median overall survival of 36 to 92 months in surgical series. Systemic chemotherapy series reported 11 to 27 months. The authors noted that no randomized trials have been done and that the surgical patients may have been healthier or otherwise different. Recurrence remained common. In one series, 82% of disease progression stayed within the abdomen. The authors also reported unpublished data from their own institution: among 113 patients clinically free of disease after a second operation, median recurrence-free survival was 39 months. The authors concluded that CRS/IPC offers survival benefit in selected patients and that close surveillance is needed. They named longer-lasting ('dwell') IPC and second operations as strategies against recurrence.

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 literature review based on a Medline search, which also included the authors' own treatment protocol and a mention of their unpublished retrospective data
• Who was studied: Published studies of patients with diffuse malignant peritoneal mesothelioma treated with surgery and/or chemotherapy. The authors also referred to their own unpublished retrospective review of 113 patients at their institution (Columbia University Medical Center, New York) who were clinically free of disease after a second operation.
• Exposure: The article does not address asbestos or any other cause of mesothelioma. Its subject is treatment: cytoreductive surgery, heated intraoperative and early post-operative intraperitoneal chemotherapy, dwell intraperitoneal chemotherapy, repeat operations, and systemic chemotherapy.
• Main results:
  • The review reported that published CRS/IPC series had median overall survival ranging from 36 to 92 months. Systemic chemotherapy series for DMPM had median overall survival ranging from 11 to 27 months.
  • The review cited Italian and US National Cancer Institute series that reported 5-year progression-free survival of 14% and 13%, respectively, after CRS/IPC.
  • The review cited one series in which 82% of disease progression after initial CRS/IPC remained confined to the abdominal cavity.
  • The review cited a meta-analysis that reported 5-year overall survival of 42% in DMPM patients undergoing CRS/IPC.
  • According to the literature reviewed, epithelioid histology and completeness of cytoreduction were the disease factors consistently associated with longer disease-free and overall survival.
  • On the basis of retrospective data, the review stated that cisplatin- and carboplatin-based heated intraperitoneal chemotherapy appeared to be associated with increased overall survival compared with mitomycin-c for DMPM.
  • In the authors' own unpublished retrospective review of 113 patients clinically free of disease after a second CRS and HIPEC, median recurrence-free survival was 39 months and the 5-year recurrence-free survival rate was 37%.
  • In the same unpublished data, there was no statistically significant difference between patients whose gross disease was debulked to less than 2.5 mm at the second operation and patients who had no gross disease requiring surgery at the second look.
  • The review reported that retrospective studies of repeat CRS/IPC for recurrent or progressive disease did not show increased operative morbidity or mortality in the second operations.
• The authors' conclusion: The authors concluded that CRS/IPC offers survival benefit in selected patients with DMPM, but that the high rate of recurrence means close surveillance is needed after surgery. They named dwell IPC and a second CRS/IPC as strategies to prevent and treat recurrent disease.
• Limitations the authors state:
  • No randomized controlled trials have compared CRS/IPC with systemic chemotherapy for DMPM.
  • Patients in the surgical series may have had individual factors, such as younger age or exclusion for comorbidities, that contributed to their better survival.
  • Intraperitoneal chemotherapy techniques and regimens are not standardized, which makes them hard to compare.
  • The benefit the authors propose for dwell chemotherapy has not been studied in a comparative manner and is their theory.
  • Survival reports for repeat operations are affected by selection bias, because patients were identified retrospectively and had to be healthy enough to undergo another operation.
  • There are no prospective data to identify the best way of giving intraperitoneal chemotherapy.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Prognosis, Systemic Therapy, Cytoreductive Surgery, Chemotherapy.

Related studies

• Recurrence of Optimally Treated Malignant Peritoneal Mesothelioma with Cytoreduction and Heated Intraperitoneal Chemotherapy — D.R. Heller, C. Chiuzan, et al. (2017)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Iterative procedures combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated peritoneal recurrence — M. Vaira, M. Robella, et al. (2014)
• Recurrent peritoneal mesothelioma with long-delayed recurrence — A. Tandar, G. Abraham, et al. (2001)
• Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis — J.F. Wong, G.H. Tan, et al. (2015)
• Remote Recurrence of Benign Multicystic Peritoneal Mesothelioma — C.E. Lee, A. Agrawal (2017)

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