Surgical Treatment of Malignant Peritoneal Mesothelioma: Past, Present, and Future

Abstract

Malignant peritoneal mesothelioma (MPM) is a rare malignancy that arises from the serosal membranes of the abdominal cavity. In 1972, Moertel published a paper characterizing the clinical course of patients afflicted with MPM and the now recognized clinical features associated with tumor progression within the abdominal cavity. 1 Borow first reported the association between asbestos exposure and mesothelioma that same year. 2 Despite the current recognition that MPM is a distinct entity from its pleural variant, progress in the treatment of patients afflicted with MPM has been hampered by several factors. First, it is an extraordinarily rare condition: only 10‐15% of all patients with mesothelioma present with the peritoneal form of the disease, and this translates into approximately 300‐400 cases in the USA annually. As a consequence, throughout the last two decades many clinical trials testing systemic agents for patients with malignant mesothelioma did not distinguish between those with the pleural versus the peritoneal form of disease. 3‐5 Many of these trials included a small number of patients with MPM and for whom no confident conclusions regarding efficacy of the experimental regimen could be made. It is now becoming increasingly recognized that patients with MPM have a distinct disease for which specific therapies should be developed. Another significant feature of MPM that has challenged our ability to understand the contribution of various therapeutic interventions to patient outcome is the remarkable variability in the biology of this condition. In 1973, Rogoff and colleagues reported outcomes in four patients treated at Memorial Sloan‐Kettering Cancer Center in New York using surgical cytoreduction and whole-abdominal radiotherapy. 6 Two of the four patients survived longer than 5 years. Antman and colleagues reported outcomes of 37 patients with MPM treated at the Dana Farber Cancer Institute and the Brigham and Women’s Hospital between 1965 and 1984 and also noted that, while some patients progressed and succumbed rapidly, others survived for many years after treatment. 7 In their series, patients treated after 1982 underwent cytoreduction, placement of an intraperitoneal (IP) catheter, and received between 8‐10 cycles of IP doxorubicin and cisplatin. Subsequent to that 30 Gy of whole-abdominal radiation was administered. In their analysis, patients with smaller tumor burden and female gender had prolonged survival; those with epithelioid tumors did poorly compared with those with other histopathological types. Since that initial description, the use of multimodal therapy using cytoreduction with some form of high-dose regional chemotherapy has become increasingly