Malignant Peritoneal

Mesothelioma
Brian W. Loggie, MD
Address
Department of Surgery, Division of Surgical Oncology,
The University of Texas Southwestern Medical Center at Dallas,
1400 Eighth Avenue, Suite 101, Fort Worth, TX 76104, USA.
E-mail: bloggie@cans.org
Current Treatment Options in Oncology 2001, 2:395399
Current Science Inc. ISSN 1527-2729
Copyright 2001 by Current Science Inc.

Opinion statement
This paper summarizes the authors thoughts about the use of cytoreductive surgery
combined with intraperitoneal hyperthermic chemotherapy (CS-IPHC) for treatment
of peritoneal malignant mesothelioma. Pleural malignant mesotheliomas are by far
more common (about ten- to thirty-fold) than the peritoneal variants (2.2 cases
per 1 million in the US) [1]. Other locations (pericardium, tunica vaginalis) are very
rare. It is well known that chemotherapy for mesothelioma is largely unsatisfactory,
and measurement of treatment responses can be difficult. Single agent responses are
all less than 20% with currently available agents for systemically administered drugs.
Multiple drug combinations are typically more toxic, and have yielded little consistent
demonstrable benefit with major studies reporting median survivals consistently under
a year. There is currently more attention being paid to the response category of
stable or absence of disease progression in concert with quality of life measurements; all regimens show poor durability. With peritoneal malignant mesothelioma,
malignant ascites is a common presentation and a major factor in disease-related morbidity and mortality. Interperitoneal administration of agents is attractive,
but drug distribution is an issue, as are response rates and durability. Multiple
treatments are required; further, all neoplasms with peritoneal dissemination are
typically understaged by current radiologic tests (CT, MRI), and the variable uptake
of sugar by the small bowel limits the use of positron-emission tomography (PET)
imaging for peritoneal malignant mesothelioma. Also, symptoms of bowel obstruction
are not uncommon, and any mechanical component of obstruction will not improve
with any form of chemotherapy. The authors approach relies on surgery to achieve
the following: 1) accurate staging; 2) tumor debulking, as possible, and treatment
of mechanical obstruction as well as prevention of impending obstruction by resection
or bypass; and 3) preparation for the use of intra-operative hyperthermic chemotherapy perfusion. This approach has been associated with rapid clinical symptom
improvement, as well as a reliable and durable resolution of ascites with a single
therapy. Morbidity and mortality have been acceptable with about 27-month median
survival. The inability to provide effective systemic therapy to maintain or consolidate
these gains is problematic.

Introduction
For all malignant mesothelioma, etiology is most
strongly linked to environmental exposure to asbestos
and erionite. There is considerable lag time between
exposure and onset of disease (up to 30 years). For this
reason, although these factors have been recognized

and contained or limited, the disease continues to rise

in incidents in North America (peak incidence
estimated 2010) and in Europe (with an estimate of
250,000 deaths over the next 25 years). Further, not all
cases can be associated with asbestos exposure (perhaps