Study Finds Benefits to Second Peritoneal Mesothelioma Surgery
April 13, 2022
Patients with peritoneal mesothelioma cancer can survive considerably longer if they are willing and able to undergo a second aggressive surgery following tumor recurrence.
History has proven that an incentive for a repeat surgery is there.
A recent 30-year retrospective review at Wake Forest Baptist Medical Center has shown how beneficial the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, or HIPEC, can be for several cancers with peritoneal metastasis.
“People often think it’s a one-and-done procedure,” Wake Forest Baptist surgical oncologist Dr. Edward Levine told The Mesothelioma Center at Asbestos.com. “But it’s not always that way. For some, a repeat surgery can be a real life-extending event.”
Annals of Surgical Oncology published the review in March. It was co-authored by members of Wake Forest’s surgical oncology and biostatistics and data science departments.
Wake Forest Baptist Medical Center is one of the world’s most acclaimed facilities for the treatment of peritoneal malignancies. It was among the first to establish a HIPEC program, in 1991.
Mesothelioma Surgery with HIPEC Extends Survival
Cytoreductive surgery is an aggressive and lengthy procedure designed to remove all visible tumor cells from the abdomen. It can include removing parts or all of the gallbladder, liver, pancreas, spleen and intestinal tract.
HIPEC, used immediately after the surgery, involves circulating heated chemotherapy throughout the abdominal cavity in hopes of killing any microscopic tumor cells left behind by the surgeon.
The recent single-center study involved 156 patients from 1991-2021 who received the cytoreductive surgery and HIPEC combination at least twice.
During that period, 1,547 patients were treated with the combination at least once for a peritoneal malignancy, mostly for appendix, colorectal or mesothelioma cancers.
Of the 156 repeat-surgery patients, 17 had peritoneal mesothelioma. Appendix cancer dominated the repeat-surgery group with 102.
The 156 patients who received the combination multiple times had a median survival of 10.7 years, compared to just 2.5 years for those having it only once. Seventeen patients underwent the procedure three times and one patient was treated with it four times.
Peritoneal mesothelioma patients receiving the treatment at least twice had a median survival of 67.7 months, more than double the estimated median survival for patients receiving it only once.
The mesothelioma patients in the review also had a median survival of 32.2 months after the second surgery, compared to 40.1 months for those with colorectal cancer.
Surgery Remains Best Treatment for Recurrence
“Historically, I think this has shown if there is a recurrence, another surgery is still the best treatment when it comes to survival,” Dr. Perry Shen, a Wake Forest Baptist surgical oncologist and study co-author, told The Mesothelioma Center. “Tolerating multiple major operations can be done – with the right patients.”
Peritoneal mesothelioma is a rare cancer most often caused by an exposure to asbestos and diagnosed in fewer than 500 people annually in the U.S. Both Levine and Shen emphasized the importance of patients being treated at a specialty center with considerable experience in selecting patients for surgery.
Although the combination of cytoreductive surgery and HIPEC is considered the most effective treatment for mesothelioma, fewer than half of those diagnosed receive it. Most oncologists rarely see the disease and treat it only with standard chemotherapy, leading to an average survival of less than one year.
Peritoneal Mesothelioma Surgery Underutilized
One recent study, conducted by researchers at Inova Fairfax Medical Campus in Virginia, found that a large percentage of patients who could have been helped by cytoreductive surgery and HIPEC – and had their survival extended significantly – were not having the surgery for various reasons.
Although some patients are denied surgery because of age, overall health reasons or disease progression, those are not the majority with peritoneal mesothelioma.
One reason for the lack of surgery is its association with the tougher-to-treat and more prevalent pleural mesothelioma, which develops in the thoracic cavity and has a much shorter survival time.
Only an estimated one-fourth of the patients with pleural mesothelioma even qualify for aggressive surgery.
This most recent review at Wake Forest also showed little difference in complication rates between the first surgery and second, for both the overall group and the peritoneal mesothelioma group.
For the 17 mesothelioma patients undergoing repeat surgery, only two had serious complications after the first surgery and just three had complications after the second surgery.
“When you looked at the data, it was a pleasant surprise. The complication rates were comparable,” Shen said. “Part of that is, we’re selecting patients who we think can do well with it. It’s another reason patients should go to a high-volume center with experience. The procedure can extend survival.”