Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma: patient selection and special considerations

Our plain-English summary of Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma: patient selection and special considerations, by L.M. Enomoto, P. Shen, E.A. Levine, et al (Cancer Management and Research, 2019).

The study

• Authors: L.M. Enomoto, P. Shen, E.A. Levine, K.I. Votanopoulos
• Journal: Cancer Management and Research
• Published: 2019;11:4231-4241
• Type of article: Review
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant peritoneal mesothelioma (MPM) is a rare, aggressive malignancy that typically presents with vague symptoms, ascites, and/or diffuse peritoneal studding. Despite findings of advanced disease within the peritoneal cavity, spread beyond the abdomen is uncommon. Although advances in systemic chemotherapy have been made, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remain the mainstay of treatment. Median overall survival of approximately 50 months with CRS/HIPEC has been demonstrated, with age, gender, histologic subtype, peritoneal carcinomatosis index, comorbidities, nodal and extra-abdominal metastases, and completeness of cytoreduction all playing a role in prognosis. In patients with refractory malignant ascites and unresectable disease, complete resolution of ascites and improvement in quality of life have been demonstrated with palliative HIPEC. In appropriately selected patients, CRS/HIPEC plays a critical role in the treatment and palliation of MPM.

In plain English

This article was a narrative review of malignant peritoneal mesothelioma (MPM), a cancer of the lining of the abdomen. The authors work at Wake Forest Baptist Medical Center. It covered how common the disease is, how it is diagnosed and treated, and how patients fare. It did not report a new study; its figures came from earlier published work, some from the authors' own institution. On asbestos, the authors wrote that MPM is less clearly associated with asbestos than pleural mesothelioma, "if at all". They also wrote that at their institution asbestos bodies had never been found in tissue removed from MPM patients. The review mainly concerned cytoreductive surgery with heated chemotherapy washed through the abdomen (CRS/HIPEC). In the largest registry it cited, covering 405 patients, median overall survival was 53 months and 5-year survival was 47%. In an earlier study from the authors' institution, survival at 1, 2 and 3 years was 80% with cisplatin, against 47%, 47% and 42% with mitomycin. The authors noted that no randomized trials exist and concluded that surgery remains the mainstay of treatment.

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 (no new data collected)
• Who was studied: Published research on malignant peritoneal mesothelioma, mostly single-institution case series and multi-institutional cohort studies. The review gives no defined search method or number of studies reviewed.
• Exposure: Not an exposure study; the review concerns treatment with cytoreductive surgery and HIPEC. On asbestos, the authors stated that MPM is less clearly associated with asbestos than pleural mesothelioma, and that asbestos bodies had never been found in MPM resection specimens at their institution.
• Main results:
  • The authors reported that at their institution, asbestos bodies have never been found in pathologic specimens from MPM resections.
  • In the largest cited multi-institutional registry (405 patients treated with CRS/HIPEC at eight institutions), median overall survival was 53 months. Survival at 1, 3 and 5 years was 81%, 60% and 47%.
  • A cited meta-analysis of 20 studies and 1,047 patients found median overall survival ranging from 19 to 92 months.
  • In an earlier study at the authors' institution, overall survival at 1, 2 and 3 years was 80%, 80% and 80% for patients perfused with cisplatin. For patients perfused with mitomycin it was 47%, 47% and 42%. Median overall survival was 40.8 months for cisplatin and 10.8 months for mitomycin, a difference the review says did not reach statistical significance.
  • In a cited registry analysis, median overall survival after CRS/HIPEC was 94, 67, 40 and 12 months for completeness-of-cytoreduction scores 0, 1, 2 and 3.
  • In work from the authors' institution on the biphasic subtype, median overall survival was 6.8 years after a complete (CC-0) resection and 2.8 years after a CC-1 resection.
  • In a study at the authors' institution of HIPEC for malignant ascites, 299 patients underwent 310 procedures; 15% had MPM. Ascites completely resolved in 93% of patients.
• The authors' conclusion: The authors concluded that surgical resection (CRS/HIPEC) remains the mainstay of treatment for MPM. They expect future treatment to combine surgery with systemic therapy.
• Limitations the authors state:
  • The authors stated that there are no randomized controlled trials on MPM.
  • The authors stated that there is no standardized HIPEC technique because of a lack of trials and comparison studies.
  • For the cisplatin versus mitomycin comparison, the authors attributed non-significant differences to the small number of patients and the shorter follow-up of the cisplatin group.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Ascites, Peritoneal Cavity, Chemotherapy, Median Overall Survival, Histological Subtype.

Related studies

• Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — G. Glockzin, H.J. Schlitt, et al. (2009)
• Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy — K.I. Votanopoulos, C. Ihemelandu, et al. (2012)
• Is Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Justified for Biphasic Variants of Peritoneal Mesothelioma? Outcomes from the Peritoneal Surface Oncology Group International Registry — K.I. Votanopoulos, P. Sugarbaker, et al. (2018)
• Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin — A.U. Blackham, P. Shen, et al. (2010)
• Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma — A.U. Blackham, E.A. Levine (2012)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)

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