Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature

Our plain-English summary of Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature, by K. Stamou, D. Tsamis, N. Pallas, et al (International Journal of Hyperthermia, 2015).

The study

• Authors: K. Stamou, D. Tsamis, N. Pallas, E. Samanta, N. Courcoutsakis, P. Prassopoulos, A.A. Tentes
• Journal: International Journal of Hyperthermia
• Published: 2015;31(8):850-6
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Encouraging results on survival of patients with malignant peritoneal mesothelioma have been shown with the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy. This study explores the impact of aggressive surgical treatment on overall survival of peritoneal mesothelioma.

Methods: This is a retrospective analysis of prospectively collected clinical data of all patients with diagnosis of malignant peritoneal mesothelioma treated in a designated referral centre in Greece. All patients were offered cytoreductive surgery and intraperitoneal chemotherapy. Patient's characteristics, operative reports, pathology reports, and discharge summaries were stored in an electronic database and later reviewed and analysed.

Results: Cytoreduction for peritoneal mesothelioma was performed on 20 patients (15 men and 5 women) with a mean age of 59.4 years (SD 16.1). Mean peritoneal cancer index was 16.1 (SD 10.4) and the median completeness of cytoreduction score was 2 (range 1-2). Mean overall survival was 46.8 months (SE 4.03) with a mean of 21.4 and median of 18 months of follow-up. Disease-specific survival was 100% for the observed period. Univariate analysis showed the completeness of cytoreduction as the only possible predictor of survival. A median of 10 (range 4-14) peritonectomy procedures were performed per patient. Median hospital stay was 14 (range 10-57 days). Grade III and IV complications occurred post-operatively in 5 patients (25%). Two patients died in the post-operative period of pulmonary embolism and myocardial infarction.

Conclusion: Cytoreductive surgery with HIPEC has proved the most effective treatment even when taking account of the cost of significant morbidity.

In plain English

This article reported one Greek referral centre's experience treating malignant peritoneal mesothelioma, a cancer of the abdominal lining. This observational study covered 15 men and 5 women (mean age 59.4) referred from 1999 to 2014, followed by a literature review. The planned treatment was cytoreductive surgery, which removes visible tumour, plus chemotherapy inside the abdomen. Thirteen received heated chemotherapy (HIPEC) alone, two HIPEC plus post-operative chemotherapy, two post-operative chemotherapy alone, and three none because too much tumour remained. The article did not report the patients' asbestos exposure. Mean overall survival was 46.8 months; median follow-up was 18 months. In a one-factor-at-a-time analysis, how completely the tumour was removed was the only possible predictor of survival. Sex, age, performance status, tumour volume and grade, and chemotherapy before surgery showed no statistically significant link with survival. Serious complications occurred in five patients. Two died after surgery, of a pulmonary embolism and a heart attack. The authors concluded that surgery with HIPEC was the most effective treatment despite significant complications. They noted their study had few women. Some figures in the article conflict.

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: Single-centre observational cohort study (described as a case series) using prospectively collected data, followed by a review of the literature in the discussion
• Who was studied: 20 patients (15 men and 5 women), mean age 59.4 years (SD 16.1, range 16 to 73), with diffuse malignant peritoneal mesothelioma, referred to a designated centre for peritoneal surface malignancy in Greece between 1999 and 2014
• Exposure: The exposure studied was treatment, not asbestos. All patients had cytoreductive surgery. Most received HIPEC with cisplatin (50 mg/m2) and doxorubicin (15 mg/m2) for 90 minutes at 42.5 to 43.0 C. Some received early post-operative intraperitoneal chemotherapy (EPIC) with 5-fluorouracil (400 mg/m2). The three patients with CC-3 operations received no intraperitoneal chemotherapy. The patients' asbestos exposure was not reported.
• Main results:
  • Of the 20 patients, 13 received HIPEC only, 2 received EPIC only, and 2 received both. Three received no intraperitoneal chemotherapy because their cytoreduction was CC-3.
  • Among the 20 patients, mean overall survival was 46.8 months (SE 4.03). Follow-up was a mean of 21.4 months and a median of 18 months.
  • The authors reported disease-specific survival of 100% for the observed period of 52 months
  • Three operations were assessed as CC-3 (tumour left behind), and these patients were considered to have residual disease. Another three patients had a recurrence at 11, 16 and 19 months.
  • In univariate analysis, the completeness of cytoreduction (CC) score was the only possible predictor of survival
  • None of the following factors showed a statistically significant association with survival or local recurrence in this 20-patient series: sex, age, performance status, tumour volume and grade, and neo-adjuvant chemotherapy. Table 1 marks each as ns.
  • Giving HIPEC together with EPIC showed no evident survival benefit
  • Grade III and IV complications occurred in five patients. The body of the article gives this as 20%; the abstract gives it as 25%.
  • Two patients died in the post-operative period, one of pulmonary embolism and one of myocardial infarction. The authors put post-operative mortality at 10% and said they believed this was random.
  • Median hospital stay was 14 days, ranging from 10 to 57 days
• The authors' conclusion: The authors concluded that cytoreductive surgery with HIPEC has proved the most effective treatment, even taking into account the cost of significant morbidity
• Limitations the authors state:
  • Because few women were included, the study probably failed to show a significant trend by sex

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, Cytoreductive Surgery, HIPEC, Chemotherapy, Overall Survival, Pathology Report, Peritoneal Cancer Index (PCI).

Related studies

• Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — F. Struller, I. Koenigsrainer, et al. (2017)
• Radiological predictors of complete cytoreduction in 59 patients with peritoneal mesothelioma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a UK referral centre — A. Chandramohan, A. Thrower, et al. (2017)
• Iterative procedures combining cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated peritoneal recurrence — M. Vaira, M. Robella, et al. (2014)
• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Adolescent and Young Adults with Peritoneal Metastases — M. Dhir, L. Ramalingam, et al. (2017)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent peritoneal metastases — T.C. Chua, L.E. Quinn, et al. (2013)

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