[Malignant peritoneal mesothelioma. Our experienced with triple combined therapy: cytoreduction, intraperitoneal perioperative chemotherapy and hyperthermia]
ABSTRACT
INTRODUCTION: Malignant peritoneal mesothelioma is the most common primary neoplasm of the serous peritoneum. Most patients die of the complications of local disease confined to the peritoneal cavity, while nodal or distant dissemination is extremely rare. Prognosis with traditional therapeutic options is dismal, with a median survival of between 4 and 12 months from diagnosis. The application of a new combined therapy with cytoreductive surgery, intraperitoneal perioperative chemotherapy and heated intraperitoneal intraoperative chemotherapy, followed by early postoperative intraperitoneal chemotherapy is currently providing good results, in some instances even allowing curative intent. We present a series of patients treated with this triple combined therapy.
MATERIAL AND METHOD: Between December 1998 and December 2005, 78 cytoreductive surgeries were performed in 50 patients in our peritoneal carcinomatosis program at the San Jose Policlinic in Vitoria (Spain), for distinct reasons. Among these patients, surgery was performed on 11 occasions in seven patients with a diffuse malignant peritoneal mesothelioma. The present study focuses on this latter group of seven patients.
RESULTS: Eleven cytoreductions were performed in seven patients with diffuse malignant peritoneal mesothelioma. There were four men and three women, with a mean age of 50 years (range 31-57 years). None of the patients had a history of occupational exposure to asbestos or contact with this substance. All the patients had received more than one surgical intervention before entering our program. Only two patients had also received systemic chemotherapy as adjuvant treatment after their initial diagnosis, as the only possible therapeutic alternative. Treatment with curative intent was provided, obtaining complete cytoreduction of macroscopic disease in all patients, followed by application of intraperitoneal perioperative chemotherapy for the treatment of any residual microscopic disease. Pathologic analysis showed biphasic sarcomatous mesothelioma in two patients and epithelial mesothelioma in the remaining five patients. Postoperative complications occurred in five patients, resulting in a mean length of postoperative hospital stay of 41.5 days (range 17-84 days). Three patients died from disease progression at 3, 9 and 11 months after the initial cytoreduction; of these, two patients had diffuse biphasic sarcomatous mesothelioma. The remaining four patients are still alive at 5, 9, 19 and 54 months after the initial cytoreduction without evidence of disease at the present time.
CONCLUSIONS: Radical oncologic cytoreductive surgery combined with intraperitoneal perioperative chemotherapy provides good results with prolonged survival in selected cases, although morbidity is high. Based in our experience, biphasic sarcomatous mesotheliomas should be excluded from this protocol because of their aggressiveness; these tumors should be included only in conventional therapeutic strategies with palliative intent.