Treatment of Patients with Malignant Peritoneal Mesothelioma

Our plain-English summary of Treatment of Patients with Malignant Peritoneal Mesothelioma, by C.Y. Li, T. Kennedy, H.R. Alexander (Journal of Clinical Medicine, 2022).

The study

• Authors: C.Y. Li, T. Kennedy, H.R. Alexander
• Journal: Journal of Clinical Medicine
• Published: 2022;11(7)
• Type of article: Review
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant peritoneal mesothelioma is a rare malignancy arising from the serosa of the peritoneal cavity. It is diagnosed based on suspicious findings on cross sectional imaging and a tissue biopsy showing confirmatory histologic and immunohistochemical features. The disease is hallmarked by its propensity to progress mainly in the peritoneal cavity. In selected patients, surgical cytoreduction and hyperthermic intra-operative peritoneal chemotherapy has become the initial preferred treatment and is associated with provide prolonged in many patients. Systemic chemotherapy using a couplet of cisplatin or gemcitabine with pemetrexed has modest response rates and duration of response. Expression of PD-L1 has been demonstrated in peritoneal mesothelioma tumors and there has been significant interest in the use of check point blockade targeted against PD-L1 in this clinical setting. Future clinical research using a combination of check point blockade with surgical cytoreduction is a high clinical priority.

In plain English

This article was a review, not a new study of patients. The authors summarized published research on diagnosing and treating malignant peritoneal mesothelioma, a cancer of the lining of the abdominal cavity. In the background, they noted that the link between asbestos exposure and peritoneal mesothelioma is not as strongly established as it is for pleural mesothelioma. Across the retrospective studies they reviewed, patients treated with cytoreductive surgery plus heated intraperitoneal chemotherapy (HIPEC) had median overall survival of 3 to 5 years and 5-year survival of 36% to 53%. In one cited national database study, median survival was 38 months for patients who had surgery and 7 months for those who did not. For this type of operation in general, the authors reported operative mortality of about 2% and major complications in 20% of patients. They described the data on immunotherapy for peritoneal mesothelioma as very limited. The authors concluded that, in selected patients, surgery with HIPEC is associated with durable survival. They noted that the surgical studies were retrospective and largely uncontrolled.

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 on the diagnosis and treatment of malignant peritoneal mesothelioma
• Who was studied: No new patients were studied. The review covered published studies of patients with malignant peritoneal mesothelioma, including single-center and multi-center series and national databases from the United States (NCDB, SEER) and France (RENAPE).
• Exposure: Treatments for malignant peritoneal mesothelioma: cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC), systemic chemotherapy (cisplatin or gemcitabine with pemetrexed), and immune checkpoint inhibitors. Asbestos exposure and germline BAP1 mutations were mentioned only as background risk factors.
• Main results:
  • Background stated by the authors: the association between asbestos exposure and peritoneal mesothelioma is not as strongly established as for pleural mesothelioma. They cited a Selikoff et al. follow-up of almost 18,000 asbestos insulation workers that observed a markedly higher than expected incidence of peritoneal mesothelioma.
  • Across the retrospective studies reviewed, median overall survival after cytoreductive surgery and HIPEC was between 3 and 5 years, and 5-year actuarial overall survival was between 36% and 53%.
  • In a cited National Cancer Database study (Bijelic et al.), 701 patients had surgery and 1055 did not. Overall survival was 38 months in the surgery group versus 7 months in the group without surgery.
  • For cytoreduction and HIPEC across a number of different indications, operative mortality was approximately 2% and major morbidity occurred in 20% of patients.
  • In a cited review of 100 patients, median actuarial overall survival after cytoreduction and HIPEC was 12 months in patients with an elevated platelet count at diagnosis, compared with 55 months in patients with normal platelet counts.
  • In a cited trial of pemetrexed alone or with cisplatin in 98 surgically unresectable patients, response rates were 25% in chemotherapy-naive patients and 23.3% in previously treated patients. Median survival was 13.1 months.
  • In a cited phase II trial of atezolizumab plus bevacizumab in 20 patients with advanced, unresectable peritoneal mesothelioma, the objective response rate was 40%.
• The authors' conclusion: The authors concluded that, in select patients, cytoreduction with HIPEC is associated with durable progression-free and overall survival. They also concluded that combining checkpoint blockade with surgical resection, or using regional immunotherapy, deserves continued investigation.
• Limitations the authors state:
  • No prospective studies have addressed the specific therapeutic contribution of HIPEC in peritoneal mesothelioma.
  • Because the studies comparing chemotherapy agents used during HIPEC were largely uncontrolled, it is impossible to know whether the choice of drug or some other factor explained the differences in outcomes.
  • There are very limited data on immunotherapy in peritoneal mesothelioma; most immunotherapy studies involved pleural mesothelioma, and their relevance to peritoneal disease is not exactly known.

Topics

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Peritoneal Cavity, Biopsy, Cytoreductive Surgery, Chemotherapy, Cisplatin, Gemcitabine, Pemetrexed (Alimta).

Related studies

• Treatment of primary peritoneal mesothelioma by continuous hyperthermic peritoneal perfusion (CHPP) — B.J. Park, H.R. Alexander, et al. (1999)
• 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)
• Current concepts in the evaluation and treatment of patients with diffuse malignant peritoneal mesothelioma — K. Turner, S. Varghese, et al. (2012)
• Surgical treatment of malignant peritoneal mesothelioma: past, present, and future — H.R. Alexander (2010)
• What made hyperthermic intraperitoneal chemotherapy an effective curative treatment for peritoneal surface malignancy: A 25-year experience with 1,125 procedures — G. Passot, D. Vaudoyer, et al. (2016)
• Peritoneal mesothelioma: PSOGI/EURACAN clinical practice guidelines for diagnosis, treatment and follow-up — S. Kusamura, V. Kepenekian, et al. (2021)

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