Repeating an aggressive procedure that removes recurring cancer tumors from a patient’s abdominal cavity and bathes the area in a heated chemotherapy solution is extending the lives of some peritoneal mesothelioma patients.
A recent retrospective analysis of 161 peritoneal mesothelioma patients at the Washington Cancer Institute shows those who repeated cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) two or three times after the initial procedure are living five, 10 or more years beyond their prognosis.
The median overall survival rate at the cancer institute was 77 months for those undergoing an initial CRS and HIPEC treatment, and 55 months for those who repeated the procedure.
“The second procedure is almost like resetting the clock,” Washington Cancer Institute surgeon Chukwuemeka Ihemelandu, M.D., told Asbestos.com. “Recurrence does not mean you are nearing the end. There is the option of undergoing a second, or even third, procedure. We’ve proven it can be done safely.”
The analysis, which examined all patients from 1989 to 2012 at the cancer center, was published last month in Annals of Surgical Oncology.
Explaining the Process
Peritoneal mesothelioma is a rare, aggressive cancer that starts in the thin layer of tissue that surrounds the abdominal organs. It is caused by the ingestion of microscopic asbestos fibers. Without treating it aggressively, the typical life expectancy is only 6-12 months.
It is diagnosed in an estimated 1,000 people annually in the U.S.
Cytoreductive surgery, also known as debulking, includes the removal of the lining and all visible cancer cells throughout the abdominal area of a person with peritoneal mesothelioma.
The subsequent HIPEC involves using a heated, chemotherapy-based solution to bathe the internal abdominal area before it is drained.
The HIPEC is designed to kill any remaining cancer cells left after surgery. The CRS/HIPEC combination is a complex procedure that requires at least eight hours in the operating room.
Only 44 of the original 161 patients repeated the original procedure after seeing radiographic evidence of recurrence, and they formed the basis of the study. Another 10 patients were explored for possibly repeating the procedure, but extensive tumor involvement prevented them from having another complete resection.
Patients undergoing a second or third procedure had shorter surgeries, less intraoperative blood loss and shorter hospital stays than the first-time group of patients. The median follow-up time for the initial CRS and HIPEC group was 28 months, but 31 months for the repeat group.
“Some surgeons are a little leery about going back into the abdominal area a second time. It makes things a little more difficult, quite challenging even in the right hands,” Ihemelandu said. “Our patients, though, are usually full-speed ahead. They know we can do it safely.”
Researchers said the five-year survival was 52 percent following the initial procedure and 46 percent following a second procedure. There was no 30-day mortality following any of the repeat procedures.
Washington Cancer Institute at the Forefront
There are a limited number of cancer centers equipped to do the CRS and HIPEC procedure for abdominal cancers.
“It’s very, very important. I can’t stress enough that being in the right hands, in the right center, can make all the difference,” Ihemelandu said. “Patients just have better survival rates where the procedure is done in high volume.”
The Peritoneal Surface Oncology division at the Washington Cancer Institute is headed by renowned surgeon Paul Sugarbaker, M.D., who helped pioneer the CRS/HIPEC procedure more than a decade ago. He is the brother of David Sugarbaker, M.D., the pleural mesothelioma specialist who recently moved from Brigham & Women’s Hospital in Boston to the Baylor College of Medicine in Houston.
Under Paul Sugarbaker’s expertise, the Washington Cancer Institute has integrated a unique, five-chemotherapy-drug cocktail to use with the HIPEC.
“We call it the kitchen sink approach,” said Ihemelandu, who believes it is the only cancer center in the U.S. using the combination with the HIPEC.
The cocktail includes chemotherapy drugs cisplatin, doxorubicin, ifosfamide, paclitaxel and pemetrexed. The repeat procedures include the chemotherapy drug melphalan.
“I think for the most part, we’ve perfected the surgery itself,” he said. “The future now is finding the exact drug regimen that gives patients the best survival benefit.”
Earlier Study at Moffitt
This latest study accentuated a smaller one done last year at the Moffitt Cancer Center in Tampa. The Moffitt study involved 29 patients with peritoneal mesothelioma, but it also emphasized the benefits of doing a second round of surgery and HIPEC.
The median survival rate overall there was 41 months, but for the eight patients who underwent a second procedure, the median survival was 80 months.
As the techniques of combining cytoreductive surgery with HIPEC in the treatment of peritoneal mesothelioma patients continue to develop, there is hope that patients with this aggressive cancer can enjoy longer lives.