Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma.

Abstract

Sugarbaker et al are to be congratulated for their comprehensive review of the management of malignant peritoneal mesothelioma using cytoreductive surgery (CRS) and perioperative chemotherapy. Their report encompasses the entirety of care for patients with malignant peritoneal mesothelioma, from diagnosis and treatment to morbidity and mortality resulting from CRS, and the role of hyperthermic intraperitoneal chemotherapy (HIPEC). The authors also describe patient and operative risk factors to improve patient outcomes in this rare disease. Peritoneal mesothelioma was first described in 1908 byMiller andWynn. It is a rare cancer that is increasing in incidence and affects approximately 800 people per year in the United States. It was once a rapidly fatal tumor secondary to obstruction, with a median survival of 6 to 12 months. One of the first published treatment strategies for malignant peritoneal mesothelioma was by Antman et al in 1983, when they described a multidisciplinary regimen including CRS, with a median survival in responding patients of 22 months. CRS and HIPEC then quickly became the treatments of choice, with an improvement in median overall survival of 30 to 92 months. As detailed in the report by Sugarbaker et al, it is widely accepted that CRS and HIPEC represent the standards of care for peritoneal mesothelioma. Unfortunately, not everyone is a candidate for these treatments, and certain prognostic indicators are important to discuss. Although there are three histologic types of peritoneal mesothelioma, only the epithelial type has a favorable prognosis. In general, sarcomatoid and biphasic tumor types do not fare well enough to warrant treatment with CRS and HIPEC. Additionally, there is little doubt that completeness of cytoreduction plays a major role in a patient’s prognosis. Although there is some controversy, as the authors mention, between selective peritonectomy and complete parietal peritonectomy, there is broad consensus that patients with cytoreduction completeness of 0 or 1 (no disease or disease , 2.5 mm) have significantly improved survival compared with patients left with gross disease. Finally, patientsmust have the overall fitness to withstand a physically taxing surgery, where the approximate mortality is a 2% to 4%, and morbidity approaches 30% to 40%. There is some consensus about the treatment of malignant peritoneal mesothelioma with HIPEC; however, there are also many unanswered questions, which Sugarbaker et al highlight. Table 2 in their report is adapted from one of the largest multi-institutional reviews, encompassing 405 patients withmalignant peritoneal mesothelioma from 29 centers