Induction Chemotherapy Followed by Pleurectomy Decortication and Hyperthermic Intraoperative Chemotherapy (HITHOC) for Early-Stage Epitheliod Malignant Pleural Mesothelioma-A Prospective Report

Our plain-English summary of Induction Chemotherapy Followed by Pleurectomy Decortication and Hyperthermic Intraoperative Chemotherapy (HITHOC) for Early-Stage Epitheliod Malignant Pleural Mesothelioma-A Prospective Report, by S. Bongiolatti, F. Mazzoni, O. Salimbene, et al (Journal of Clinical Medicine, 2021).

The study

• Authors: S. Bongiolatti, F. Mazzoni, O. Salimbene, E. Caliman, C. Ammatuna, C.E. Comin, L. Antonuzzo, L. Voltolini
• Journal: Journal of Clinical Medicine
• Published: 2021;10(23)
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is an aggressive disease with poor prognosis and the current treatment for early-stage MPM is based on a multimodality therapy regimen involving platinum-based chemotherapy preceding or following surgery. To enhance the cytoreductive role of surgery, some peri- or intra-operative intracavitary treatments have been developed, such as hyperthermic chemotherapy, but long-term results are weak. The aim of this study was to report the post-operative results and mid-term outcomes of our multimodal intention-to-treat pathway, including induction chemotherapy, followed by surgery and Hyperthermic Intraoperative THOracic Chemotherapy (HITHOC) in the treatment of early-stage epithelioid MPM. Since 2017, stage I or II epithelioid MPM patients have been inserted in a surgery-based multimodal approach comprising platinum-based induction chemotherapy, followed by pleurectomy and decortication (P/D) and HITHOC with cisplatin. The Kaplan-Meier method was used to estimate overall survival (OS), disease-free survival (DFS) and progression-free survival (PFS). During the study period, n = 65 patients affected by MPM were evaluated by our institutional Multidisciplinary Tumour Board; n = 12 patients with stage I-II who had no progression after induction chemotherapy underwent P/D and HITHOC. Post-operative mortality was 0, and complications developed in n = 7 (58.3%) patients. The median estimated OS was 31 months with a 1-year and 3-year OS of 100% and 55%, respectively. The median PFS was 26 months with 92% of a 1-year PFS, whereas DFS was 19 months with a 1-year DFS rate of 83%. The multimodal treatment of early-stage epithelioid MPM, including induction chemotherapy followed by P/D and HITHOC, was well tolerated and feasible with promising mid-term oncological results.

In plain English

This study from Careggi University Hospital, Florence, Italy, covered early-stage epithelioid malignant pleural mesothelioma treated in 2017 to 2020. Data were collected prospectively and reviewed retrospectively, without a comparable control group. Of 65 patients assessed, 17 began platinum-based chemotherapy. Four of these progressed and one was judged unfit; the other 12 had pleurectomy and decortication plus heated cisplatin chemotherapy in the chest during surgery (HITHOC). Nine of the 12 (75%) were recorded as asbestos-exposed. No patient died within 90 days of surgery. Seven of 12 (58.3%) had complications. Four had died of mesothelioma at a median follow-up of 21 months. Estimated median overall survival from the start of treatment was 31 months (95% confidence interval 27.24 to 34.75); 3-year survival was 55%. Median disease-free survival after surgery was 19 months (95% confidence interval 14.39 to 23.6). Time from diagnosis to death was 15 months in five patients excluded from surgery versus 31 months in those operated on (not statistically significant). The authors concluded the approach was well tolerated with promising mid-term results. They noted the small sample, short follow-up and lack of a control group.

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 case series of patients treated under an institutional protocol. Data were collected prospectively in a database and reviewed retrospectively, with no comparable control group (the authors call it a prospective report). An exploratory comparison was made with 5 patients excluded from surgery.
• Who was studied: Patients with clinical stage I or II epithelioid malignant pleural mesothelioma at Careggi University Hospital, Florence, Italy, January 2017 to December 2020. Of 65 patients evaluated by the tumour board, 17 were selected for the multimodal pathway. Of these 17, 4 were excluded for disease progression and 1 as unfit, so 12 underwent surgery. Of the 12, 6 (50%) were male and the median age was 67.5 (range 47 to 78).
• Exposure: The exposure studied was a treatment: platinum-based induction chemotherapy (cisplatin or carboplatin with pemetrexed), followed by pleurectomy and decortication and hyperthermic intraoperative thoracic chemotherapy with cisplatin (standard dose 150 mg per square metre; reduced to 100 in two patients). Asbestos exposure was recorded for 9 of the 12 surgical patients; no fiber types were given.
• Main results:
  • Of the 17 patients who started induction chemotherapy, 5 were excluded from surgery: 4 because of disease progression and 1 judged unfit because of renal impairment and poor cardiac function.
  • Asbestos exposure was recorded in 9 of the 12 surgical patients (75%).
  • Among the 12 surgical patients, post-operative 30-day and 90-day mortality was 0.
  • Complications occurred in 7 of 12 patients (58.3%): chylothorax in 3 (25%), prolonged air leak in 3 (25%), and bleeding requiring surgery in 1 (8.3%).
  • At a median follow-up of 21 months (range 12 to 37), 4 of 12 patients (33.3%) had died of progression of mesothelioma, 3 (25%) were alive and disease-free, and 5 (41.7%) were alive with recurrence.
  • Median estimated overall survival from the start of treatment was 31 months (95% CI 27.24 to 34.75), with 1-year, 2-year and 3-year overall survival of 100%, 100% and 55%.
  • Median overall survival from surgery was 26 months (95% CI 21.74 to 30.25), with 1-year, 2-year and 3-year survival of 100%, 56% and 37%.
  • Median progression-free survival was 24 months in the results text (95% CI 17.83 to 30.16), with 1-year and 2-year rates of 92% and 28.5%. The abstract gives 26 months.
  • Median disease-free survival from surgery was 19 months (95% CI 14.39 to 23.6), with 1-year and 2-year disease-free survival of 83% and 0%.
  • On final pathology, 11 patients had N0 disease and one had N1 involvement. One patient showed complete pathological response.
  • Time from diagnosis to death was 15 months for the 5 patients excluded from surgery and 31 months for the 12 who had surgery. This difference was not statistically significant (p = 0.26).
• The authors' conclusion: The authors concluded that the multimodal treatment (neoadjuvant platinum-based chemotherapy followed by pleurectomy and decortication and HITHOC) was safe and effective for early-stage epithelioid malignant pleural mesothelioma. They based this on good tolerance, low treatment drop-out, no post-operative mortality and promising mid-term results.
• Limitations the authors state:
  • Small sample size from a highly selected cohort, which the authors say precluded statistical analysis of predictive factors for survival
  • Short follow-up period
  • No control group of similar patients treated without surgery

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Pleural Mesothelioma, Prognosis, Multimodal Therapy, Cytoreductive Surgery, Epithelioid, Cisplatin, Overall Survival.

Related studies

• A randomised phase II study of extended pleurectomy/decortication preceded or followed by chemotherapy in patients with early-stage pleural mesothelioma: EORTC 1205 — J. Raskin, V. Surmont, et al. (2024)
• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2011)
• Effect of intraoperative hyperthermic intrathoracic chemotherapy after pleurectomy decortication for treatment of malignant pleural mesothelioma: a comparative study — H.H. Elsayed, H.Y. Sharkawy, et al. (2024)
• A Trimodality, Four-Step Treatment including Chemotherapy, Pleurectomy/Decortication and Radiotherapy in Early-Stage Malignant Pleural Mesothelioma: A Single-Institution Retrospective Case Series Study — G. Vicidomini, C.M. Della Corte, et al. (2021)
• A feasibility study of induction pemetrexed plus cisplatin followed by pleurectomy/decortication aimed at macroscopic complete resection for malignant pleural mesothelioma — M. Shimokawa, S. Hasegawa, et al. (2013)
• 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)

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