A 51-Year-Old Woman with Advanced Peritoneal Mesothelioma and Stage 3b Chronic Kidney Disease Treated with Cytoreductive Surgery and Bidirectional Intraperitoneal Cisplatin and Ifosfamide Chemotherapy: A Case Report

Our plain-English summary of A 51-Year-Old Woman with Advanced Peritoneal Mesothelioma and Stage 3b Chronic Kidney Disease Treated with Cytoreductive Surgery and Bidirectional Intraperitoneal Cisplatin and Ifosfamide Chemotherapy: A Case Report, by M. Alaswad, F. ElKordy, H. Jaamour, et al (The American Journal of Case Reports, 2023).

The study

• Authors: M. Alaswad, F. ElKordy, H. Jaamour, A. Al Otry, A.Z. Azzam, T.M. Amin, H.A. Khoja
• Journal: The American Journal of Case Reports
• Published: 2023;24:e941726
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND Malignant mesotheliomas are rare, yet highly malignant tumors. Mesotheliomas are tumors that develop from mesothelial surfaces, with the pleura being the most common, followed by the peritoneum. The diagnosis of malignant peritoneal mesothelioma (MPM) is usually established when the disease is advanced, owing to the nonspecific clinical appearance and abdominal symptoms. Initially, MPM was treated with palliative systemic chemotherapy, with or without palliative surgery. However, cytoreductive surgery (CRS) combined with bidirectional intraoperative chemotherapy (BDIC) has recently emerged as a treatment option for MPM. BDIC creates a bidirectional chemotherapy gradient in the peritoneal tumor cells through the simultaneous use of intraperitoneal and intravenous chemotherapy. CRS, combined with BDIC (CRS-BDIC), allows the complete elimination of residual tiny tumor cells after complete removal of the visible tumor nodules. CASE REPORT Herein, we present a case of a 51-year-old woman with MPM and chronic kidney disease (CKD) stage 3b. Her treatment consisted of neoadjuvant chemotherapy and immunotherapy, followed by CRS-BDIC using intraperitoneal cisplatin and doxorubicin, and intravenous ifosfamide. The surgery was successful, with no immediate complications or decline in the patient's kidney function. On follow up 2 months later, the patient denies suffering any chemotherapy-related adverse effects, and her kidney profile remains stable. CONCLUSIONS In conclusion, nephrotoxicity, a known adverse effect of cisplatin and ifosfamide, might not be a contraindication for the use of these potentially nephrotoxic drugs in CRS-BDIC in patients with renal impairment.

In plain English

This case report described one 51-year-old woman with malignant peritoneal mesothelioma, a cancer of the abdominal lining, who also had stage 3b chronic kidney disease. The article did not report whether she had been exposed to asbestos. Her first chemotherapy cycle, cisplatin with pemetrexed, was followed by complications including febrile neutropenia and acute kidney injury that were thought to be caused by cisplatin. Her creatinine reached 162 umol/l and she needed continuous renal replacement therapy. After further chemotherapy and then immunotherapy with pembrolizumab, a scan showed only a small 6 mm remaining lesion. She then had surgery to remove tumor. This was combined with cisplatin at a 50% dose plus doxorubicin given into the abdomen, and ifosfamide at an 80% dose given into a vein. There were no immediate complications, and her kidney function stayed stable without dialysis. Two months later her creatinine was 109 umol/L. The authors concluded, based on two cases at their institution, that kidney toxicity from these drugs might not rule out this treatment in patients with kidney failure, and that further studies are required.

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: case report (one patient)
• Who was studied: One 51-year-old woman with malignant peritoneal mesothelioma and known stage 3b chronic kidney disease, referred to the authors' hospital for management
• Exposure: Not reported: the article gives no asbestos or other exposure history for this patient
• Main results:
  • Her first neoadjuvant chemotherapy cycle (cisplatin and pemetrexed) was complicated by nausea, febrile neutropenia, thrombocytopenia, bacteremia, acute kidney injury and mucositis, all thought to be cisplatin-induced. Cisplatin was then switched to carboplatin.
  • After her last chemotherapy cycle, her acute kidney injury persisted and progressed, with creatinine reaching 162 umol/l. This required continuous renal replacement therapy, after which creatinine settled at a stable baseline of 140 umol/L.
  • Because she could not tolerate more chemotherapy, she was given immunotherapy with pembrolizumab.
  • After pembrolizumab, PET-CT showed complete resolution of the previously noted mild FDG-avid peritoneal mesothelioma and of the ascites, with only a residual tiny (6 mm) lesion at the right superior omentum.
  • Before surgery her eGFR was 35 ml/min/m2 and her creatinine was 139 umol/L.
  • She had cytoreductive surgery with bidirectional intraoperative chemotherapy. This used 50% intraperitoneal cisplatin (25 mg/m2) plus doxorubicin (7.5 mg/m2) infused over 90 minutes, given at the same time as an 80% intravenous ifosfamide dose (1040 mg/m2) with mesna (208 mg/m2). The article does not state that the doxorubicin dose was reduced.
  • During the operation her urine output ranged between 2.5 and 3 ml/kg/h. The procedure went without immediate complications, and she did not require inotropes or vasopressors.
  • Her renal function remained stable during and after surgery, without the need for intraoperative or postoperative hemodialysis. On postoperative day 4, creatinine was 135 umol/L and eGFR was 36.
  • Tissue examination after surgery showed tumor cells that were positive for calretinin and negative for BER-EP4, which the authors said confirmed malignant peritoneal mesothelioma.
  • Her postoperative course was uncomplicated. At follow-up 2 months later, her kidney function remained stable, with serum creatinine 109 umol/L and eGFR 44 ml/min/m2.
• The authors' conclusion: The authors concluded that nephrotoxicity, a known adverse effect of cisplatin and ifosfamide, might not be a contraindication to using these drugs in CRS-BDIC in patients with renal failure. They based this on two cases managed at their institution, and said further studies are required.

Topics

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

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Cytoreductive Surgery, Cisplatin, Chemotherapy, Mesothelioma, Pleura, Peritoneum, Palliative Care.

Related studies

• Bidirectional Intraoperative Chemotherapy Using Cisplatin and Ifosfamide for Intraperitoneal Mesothelioma in Severe Renal Impairment: A Case Report — R. Almesned, A.Z. Azzam, et al. (2023)
• Conversion to Complete Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma After Bidirectional Chemotherapy — F. Le Roy, M. Gelli, et al. (2017)
• 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 with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin — A.U. Blackham, P. Shen, et al. (2010)
• 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)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up — P. Malekzadeh, M. Good, et al. (2021)

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