Response to Nivolumab followed by complete cytoreductive surgery with HIPEC resulted in long-term survival in a patient with sarcomatoid-predominant biphasic peritoneal mesothelioma. A case report

Our plain-English summary of Response to Nivolumab followed by complete cytoreductive surgery with HIPEC resulted in long-term survival in a patient with sarcomatoid-predominant biphasic peritoneal mesothelioma. A case report, by P.H. Sugarbaker (International Journal of Surgery Case Reports, 2023).

The study

• Author: P.H. Sugarbaker
• Journal: International Journal of Surgery Case Reports
• Published: 2023;107:108359
• Type of article: Case report
• Cited by: 6 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction And Importance: Sarcomatoid-predominant biphasic peritoneal metastases is a rapidly progressing and deeply invasive variant of this disease with survival measured in months. Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a standard of care for epithelioid peritoneal mesothelioma, the sarcomatoid variant is so aggressive, the standard treatment is not recommended. Immunotherapy has recently been utilized for pleural mesothelioma. Partial responses to immunotherapy may be combined with CRS to achieve a favorable outcome in sarcomatoid-predominant peritoneal mesothelioma.

Case Presentation: A 39-year-old woman developed an expanding abdomen. A 10 cm pelvic mass was removed by hysterectomy. With an initial diagnosis of advanced ovarian cancer, she was treated with cisplatin plus paclitaxel. Disease progression led to a review of her original pathology and a repeat biopsy which showed biphasic peritoneal mesothelioma with sarcomatoid predominance. Treatment with Nivolumab was transiently beneficial. Repeat CT 8 months later showed partial bowel obstruction and necrotic expanding tumor masses that were partially calcified. CRS with HIPEC and normothermic long-term intraperitoneal pemetrexed (NIPEC) plus intravenous cisplatin resulted in a 5-year disease-free survival.

Clinical Discussion: The specimens removed at CRS showed marked progression within large masses. Smaller masses resected with CRS showed fibrosis and calcification. The response to Nivolumab was heterogeneous with smaller masses with good blood supply adequately treated but larger masses markedly progressed.

Conclusions: A combination of partial response to immunotherapy with a complete CRS plus HIPEC and NIPEC can result in a long-term favorable outcome.

Copyright © 2023 The Author. Published by Elsevier Ltd.. All rights reserved.

In plain English

This case report described one 39-year-old woman whose pelvic mass was first treated as ovarian cancer, with a hysterectomy in December 2017 and two cycles of paclitaxel and carboplatin in January and February 2018. When the disease progressed, a pathology review and repeat biopsy changed the diagnosis to biphasic malignant peritoneal mesothelioma with predominant sarcomatoid histology. The article does not mention asbestos exposure. From March to October 2018 she received the immunotherapy nivolumab. Her tumors at first partly shrank, but a later CT scan showed masses obstructing the bowel. In November 2018 she had tumor-removal surgery with heated chemotherapy inside the abdomen (HIPEC), then five monthly doses of pemetrexed into the abdomen plus intravenous cisplatin. In the removed tissue, small nodules showed scarring and calcification with no viable cancer cells, while larger masses up to 10 cm contained viable sarcomatoid mesothelioma. As of April 1, 2023, four years after surgery, she remained free of disease. The author concluded that nivolumab combined with surgery resulted in long-term survival in this patient. The author proposed that the drug reached small, well-supplied nodules but not large, partly dead masses.

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 (single patient; data prospectively recorded and retrospectively reviewed)
• Who was studied: One 39-year-old otherwise healthy woman in the USA, with symptoms beginning in autumn 2017 and follow-up to April 1, 2023
• Exposure: The article does not report asbestos or any other exposure history. It concerns treatment: nivolumab 240 mg intravenously every 2 weeks, then cytoreductive surgery with HIPEC and long-term intraperitoneal pemetrexed (NIPEC) plus intravenous cisplatin
• Main results:
  • Diagnosis was revised from ovarian cancer to biphasic malignant peritoneal mesothelioma with a predominant sarcomatoid histology after first-line chemotherapy for presumed ovarian cancer was judged ineffective
  • During nivolumab treatment there was initially partial shrinkage of abdominal and pelvic tumor masses; a later CT showed nodules, calcification and obstruction of the rectosigmoid colon by mesothelioma
  • Pathology from the surgery showed a heterogeneous response. Small nodules had no viable cancer cells, while larger masses up to 10 cm in diameter contained viable sarcomatoid mesothelioma
  • As of April 1, 2023, five years after diagnosis and 4 years after cytoreductive surgery, the patient remained free of disease, without disability, with no further treatment after NIPEC
• The authors' conclusion: The author concluded that the combination of nivolumab and cytoreductive surgery resulted in long-term survival in this patient. The author proposed that the drug reached smaller nodules with adequate blood supply but was excluded from large, partially necrotic nodules, and suggested a possible role for cisplatin.
• Limitations the authors state:
  • The author framed the result as applying to this one patient

Topics

Medical terms in this study, explained in our Lexicon: Nivolumab (Opdivo), Cytoreductive Surgery, HIPEC, Sarcomatoid, Biphasic Mesothelioma, Peritoneal Mesothelioma, Epithelioid, Immunotherapy.

Related studies

• ASO Author Reflections: Long-Term Survival Is Feasible After Complete CRS/HIPEC for Biphasic Peritoneal Mesothelioma — K. Chouliaras, K.I. Votanopoulos (2018)
• 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)
• Complete cytoreductive surgery plus HIPEC for peritoneal metastases from unusual cancer sites of origin: results from a worldwide analysis issue of the Peritoneal Surface Oncology Group International (PSOGI) — D. Goéré, G. Passot, et al. (2017)
• Treatment factors associated with long-term survival after cytoreductive surgery and regional chemotherapy for patients with malignant peritoneal mesothelioma — H.R. Alexander, D.L. Bartlett, et al. (2013)
• Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy — B. Singh, G. Singh, et al. (2020)
• Long-term outcomes and survival analysis of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei at a newly established peritoneal malignancy centre in Japan — H. Yano, Y. Gohda, et al. (2024)

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