Hyperthermic intrapleural chemotherapy: an update

Our plain-English summary of Hyperthermic intrapleural chemotherapy: an update, by M.E. Campany, P.A. Reck Dos Santos, B.B. Donato, et al (Journal of Thoracic Disease, 2023).

The study

• Authors: M.E. Campany, P.A. Reck Dos Santos, B.B. Donato, C.M. Alwardt, V. Ernani, J. D'Cunha, S.E. Beamer
• Journal: Journal of Thoracic Disease
• Published: 2023;15(9):5064-5073
• Type of article: Review
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

The safety and efficacy of hyperthermic intrathoracic chemotherapy (HITHOC) as an adjunct to cytoreductive surgery (CRS) in pleural malignancies has been well demonstrated. This is most often described in cases of mesothelioma, thymoma, or other secondary pleural metastases. The utilization of a direct cytotoxic agent with increased penetration secondary to a hyperthermic environment is especially beneficial in pleural malignancy as a microscopic resection remains immensely challenging. Despite favorable outcomes with a limited associated risk profile, there persists a variety in utilization and technique of HITHOC described in current literature. National Comprehensive Cancer Network (NCCN) guidelines state that though intraoperative adjuvant therapies such as HITHOC have been studied, they remain of unclear benefit and definitive recommendations do not currently exist. This ambiguity limits the standardization of HITHOC, thus hindering its further application in a patient population with exceedingly poor outcomes within current guideline-based therapy. As the prevalence of pleural malignancies necessitating CRS with adjuvant HITHOC remains quite low, we believe a task force initiative to further investigate the role of HITHOC in surgical management of pleural malignancies would enable wider utility of this promising technique. Additionally, we propose that the creation of a pleural cancer index could aid in standardization of HITHOC in those with pleural malignancy.

2023 Journal of Thoracic Disease. All rights reserved.

In plain English

This was a narrative review of hyperthermic intrathoracic chemotherapy (HITHOC), in which heated chemotherapy is circulated in the chest right after surgery to remove pleural cancer. It drew on published studies and the authors' experience at their own institution. It reported no new patient data and did not study asbestos. It mentioned only as background that asbestos exposure is associated with about 85% of malignant pleural mesothelioma cases. The authors wrote that the most common uses of HITHOC in the literature were malignant pleural mesothelioma and thymic tumors spread along the pleura. Their own technique used cisplatin at 150 to 225 mg per square meter of body surface area, at 42 degrees Celsius, for 60 minutes, given in three portions. They reported wide variation between centers in drugs, temperature and duration, and noted that national guidelines give no formal recommendation. They stated that small patient numbers, varied techniques and mostly single-institution case series limited firm conclusions. The authors concluded that the evidence and their experience favored HITHOC for appropriate candidates. They proposed a task force and a pleural cancer index to standardize its use.

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 literature combined with a description of the authors' institutional technique; no new patient data were reported
• Who was studied: No study population. The review covered published literature on HITHOC in pleural cancers (malignant pleural mesothelioma, thymic tumors with pleural spread, and rarer secondary pleural cancers) and described practice at the authors' institution (Mayo Clinic, Phoenix, Arizona, USA)
• Exposure: Not an exposure study. The treatment reviewed was HITHOC given after cytoreductive surgery. Asbestos appears only as background: the authors note that asbestos exposure is associated with approximately 85% of malignant pleural mesothelioma cases
• Main results:
  • In the literature the authors reviewed, the most common indications for HITHOC with cytoreductive surgery were malignant pleural mesothelioma (MPM) and thymic pleural malignancies
  • At the authors' institution, the primary indications were stage I to IIIA epithelioid mesothelioma and stage IV thymoma with pleural dissemination
  • The authors' institutional regimen was single-agent cisplatin 150 to 225 mg/m2 of body surface area at 42 degrees Celsius for 60 minutes, with the dose given in thirds at the start, at 20 minutes and at 40 minutes
  • Across the published literature, the chemotherapy agents, temperatures and treatment durations used for HITHOC varied between institutions
  • Citing other studies, the authors noted that cisplatin is the main driver of kidney (renal) toxicity with HITHOC
  • Current NCCN guidelines for pleural mesothelioma mention hyperthermic chemotherapy but give no formal recommendation, describing intrathoracic adjuvant therapies like HITHOC as of unclear benefit
• The authors' conclusion: The authors concluded that current literature and their institutional experience favor HITHOC as an addition to cytoreductive surgery in appropriate candidates with pleural malignancies. They proposed a dedicated task force and a pleural cancer index to standardize its indications and technique
• Limitations the authors state:
  • The authors stated that the rarity of the diseases (and so limited patient numbers), together with inconsistent techniques, severely limits the ability to draw strong conclusions about how well HITHOC works
  • Much of the existing data comes from single-institution case series, and thymoma and mesothelioma patients are commonly evaluated as one population

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Intrathoracic, Cytoreductive Surgery, Mesothelioma.

Related studies

• Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience — M. Migliore, D. Calvo, et al. (2015)
• Pharmacokinetic evaluation of intrapleural perfusion with hyperthermic chemotherapy using cisplatin in patients with malignant pleural effusion — H. Sakaguchi, H. Ishida, et al. (2017)
• Pleurectomy/decortication and hyperthermic intrapleural chemotherapy for malignant pleural mesothelioma: initial experience — M. Migliore, D. Calvo, et al. (2015)
• Interim results of pleurectomy/decortication and intraoperative intrapleural hyperthermic cisplatin perfusion for patients with malignant pleural mesothelioma intolerable to extrapleural pneumonectomy — H. Ishibashi, M. Kobayashi, et al. (2015)
• Extended pleurectomy/decortication and hyperthermic intraoperative intrapleural cisplatin perfusion for malignant pleural mesothelioma — K. Okubo, H. Ishibashi, et al. (2023)
• A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma — V. Rusch, L. Saltz, et al. (1994)

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