Peritoneal Mesothelioma

Currently, therapeutic approaches vary in each institution. Common methods include palliative surgery, systemic chemotherapy, intra-abdominal chemotherapy and surgery cytoreducing with preoperative intraperitoneal chemotherapy.

The agents commonly used in chemotherapy regimens including various combinations of cisplatin, irinotecan, cyclophosphamide, doxorubicin, dacarbazine, gemcitabine and pemetrexed. Before 2003, most of the institutions relied on evidence from small phase II studies and patients treated with cisplatin and gemcitabine. This provided a median survival of 6-9 months. Since then, large trials have taken place and, more recently, has shown that the combination of cisplatin and pemetrexed leads to a median survival of 12-14 months. However, although encouraging, these results indicate that treatment of peritoneal mesothelioma with systemic chemotherapy still has a median survival of only 1 year. This is similar to what occurs in patients who are treated with a palliative approach. Therefore, their effectiveness as first line treatment is questionable. However, it is still a useful option for patients who are not appropriate surgical candidates.

Intraperitoneal chemotherapy involves the surgical insertion of a Tenckhoff catheter to allow local administration of chemotherapy inside the abdomen. When used as single intraperitoneal cisplatin treatment for peritoneal mesothelioma, the results were similar to those treated with systemic chemotherapy, with a median survival of 9 months. Therefore, no baseless claim that the non-operative approach is futile, because of poor response to treatment and poor median survival associated with it.

Current research has shown that aggressive surgery cytoreducing peritonectomy using procedures Sugar bake followed by preoperative intraperitoneal chemotherapy, which is now considered standard practice for other cancers of the peritoneal surface, dramatically improves survival. Preoperative intraperitoneal chemotherapy including intraperitoneal hyperthermia chemotherapy and early postoperative chemotherapy. Previously, the spread of a gastrointestinal tumor, from a local location to the peritoneum, was seen as a metastatic spread. Patients with peritoneal dissemination were treated with palliative. However, ontological surgery has evolved from treating only the primary tumors to classify their metastatic spread. Cytoreducing surgery and preoperative intraperitoneal chemotherapy are useful in the treatment of peritoneal dissemination because they allow the removal of the peritoneum getting sick, therefore, an adequate cytoreduction. The addition of preoperative intraperitoneal chemotherapy allows better release of the drug to the residual tumor cells after surgery cytoreducing. The warming of the perforate provides a synergistic effect with the chemotherapeutic agent and increases cytotoxicity. This treatment is currently considered as effective for treating selected patients with peritoneal carcinomatosis from appendiceal cancer, pseudomyxoma peritonei, colorectal cancer, gastric cancer, ovarian cancer and peritoneal mesothelioma and abdominopelvic sarcoma.

A Medline search of studies evaluating the use of cytoreducing surgery and preoperative intraperitoneal chemotherapy in peritoneal mesothelioma suggests a median survival of 28-35 months.

The peritonectomy comprises a median laparotomy for maximum visualization of the abdomen and pelvis. Based on the tumor burden in the various regions, is constructed peritoneal cancer index.

Preoperative intraperitoneal chemotherapy has proved a useful prognostic indicator for cancers of the peritoneal surface. Studies on colorectal and appendiceal cancers with peritoneal carcinomatosis showed that the highest scores of preoperative intraperitoneal chemotherapy was associated with the worst prognosis. Interesting it, a recent study investigating prognostic factors for peritoneal mesothelioma found that although preoperative intraperitoneal chemotherapy may have a role as a prognostic indicator, after multivariate analysis, the nuclear size of mesothelioma was the only independent factor associated with improved survival after cytoreducing surgery and preoperative intraperitoneal chemotherapy. However, intraoperative assessment of preoperative intraperitoneal chemotherapy before debunking is standard practice in the peritonectomy.

Once they scored the peritoneal cancer index, cytoreducing surgery is performed. This involves removal of all visible tumors on the surface of any viscera and the total removal of the diseased peritoneum.

Once the surgery cytoreducing, involves intraperitoneal hyperthermia chemotherapy. Chemotherapy is administered for 90 minutes at 46 ° C to achieve an intraabdominal temperature of 42 º C, this is heated to administer chemotherapy in the abdomen allows a larger concentration of the drug where it is required. The warming of the infusion can help kill cancer cells with little or no effect on normal cells, causing cytotoxic effects of more effective chemotherapeutic agent and tumor nodules softened so that the penetration of chemotherapy into the tumor is increased.

After intraperitoneal hyperthermia chemotherapy, drains are placed in the abdomen and chest and inserting a Tenckhoff catheter in the abdomen to allow subsequent instillation of chemotherapy during the early postoperative period.

Cytoreducing surgery combined with preoperative intraperitoneal chemotherapy is currently considered as the new treatment option for patients with peritoneal mesothelioma and has a median survival of about 30 months. Since this is an aggressive surgical approach associated with morbidity and mortality, prolonged survival must be balanced carefully against the potential risks. If treatment is to benefit should be offered only to carefully selected patients with a good physical condition, low volume of peritoneal disease and no extra-abdominal metastases.

The learning curve cytoreducing surgery and preoperative intraperitoneal chemotherapy associated with the outcomes of patients who were treated over a period of nearly 10 years was reported in 2 studies (one of which was the unity of the authors). The results of these 2 studies showed a demonstrable improvement in survival, morbidity and mortality over time. The very unity of the authors has conducted over 250 peritonectomy with a mortality of 2% in the last 4 years. This is attributed to improved patient selection, surgical techniques and intraperitoneal chemotherapy regimens. Studies evaluating the quality of life after surgery cytoreducing and preoperative intraperitoneal chemotherapy have reported postoperative complications that affect short-term recovery, but in the long term survival and patients experienced improved quality of life.