Contemporary Treatment of Peritoneal Mesothelioma

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Current Standard of Care for Treatment of M P M

In 2016, Sugarbaker and his colleagues summed up the current management strategies for peritoneal mesothelioma (Sugarbaker et al. 2016). They cite numerous studies of the unique institution, as well as systematic reviews that report the average survival of 3-5 years with a combined treatment using cytoreductive surgery and hyperthermic perioperative chemotherapy. In experienced centers, these remarkably improved survival statistics were achieved with a mortality of 1% and 20% morbidity.

The data had shown that a connoisseur selection is required to prevent patients from benefiting little from these interventions. Its publication in the Journal of Oncology Practice concluded that MPM patients may experience a long-term progression-free survival or significant affiliations with CRS Más Hipec. This management plan should be considered the care standard for properly selected patients with MPM in experienced centers worldwide.

Recent results with Citorreductor Surgery, Hipec and Nipec

Several reports of intraperitoneal chemotherapy followed by surgery show a marked histopathological regression of regional chemotherapy disease. In addition, most patients treated with long-term normothermic intraperitoneal chemotherapy show an answer. It is a recommended treatment for patients who have weakening ascites. Sugarbaker and Chang reported on the long-term Normothermal Intraperitoneal Chemotherapy treatments that followed cytoreductive surgery and Hipec (Sugarbaker and Chang 2017).

This long-term chemotherapy was administered through an intraperitoneal port. For 100 patients treated with CRS Más Vec and/ or EPIC, 52%survival was 52%. In 29 patients who received 6 normothermic intraperitoneal chemotherapy cycles after CRS and EPEC, 5 -year survival was 75% (p = 0.0374). The significant prognostic variables were age, gender, administered treatment, the peritoneal cancer index, and the integrity of cytoreduction by multivariate analysis. These authors concluded that long-term regional chemotherapy was associated with better survival in patients with MPM.

Evolution of Surgical Treatments

The optimal cytoreduction of all visible malignant neoplasms is essential for the treatment of MPM for maximum long-term benefit. Up to six peritonectomy procedures (Sugarbaker 2017; Deraco et al. 2009) may be required. Visceral resections and parietal/visceral peritonectomy procedures that must be used to properly resect any visible evidence of disease are shown in Table 3.1. Its use depends on the distribution and scope of the invasion of disseminated malignancy within the peritoneal space. The normal peritoneum is not removed, only what is implanted by cancer.

The reason for peritonectomy procedures and visceral resections

Peritonectomy procedures are necessary if one should treat MPM successfully with healing intention. Peritonectomy procedures are used in the areas of visible progression of cancer in an attempt to abandon the patient with the only microscopic residual facility. Isolated tumor nodules in the parietal peritoneum can be eliminated by electroporation. The involvement of the visceral peritoneum often requires resection of a stomach portion, the small intestine, or the colorectum. The cancer layer on a parietal or visceral peritoneal surface or an intestine portion requires intestinal peritonectomy or resection for complete extraction.

Locations of Malignant Peritoneal Mesothelioma

MPM peritoneal implants imply the visceral peritoneum in the highest volume in three anatomical sites (Carmignani et al. 2003). These are sites where the intestine is anchored to the retroperitoneum and peristalsis causes less movement of the visceral peritoneal surface. The colon rectosigmoid, as it emerges from the pelvis, is a non-mobile portion of the intestine. In addition, it is in a dependent site and, therefore, is often in layers by peritoneal metastasis.

In general, a complete pelvic peritonectomy requires the elimination of pelvic side walls, the peritoneum that covers the bladder, the Sin-Sac alley, and the resection of the straight colon. The ileocecal valve is another area where there is limited mobility. It is often necessary the resection the terminal ileum and a small portion of the right colon. A final site that often requires resection is the antrum of the stomach that is fixed to the retroperitoneum in the pylorus. The tumor that enters the Winslow hole accumulates in the sub-pyloric space and can eventually cause an intestinal obstruction as a result of the obstruction of the gastric output (Sugarbaker 2002).

Electroevaporative Surgery

To properly perform the peritonectomy, the surgeon must use Electrourgery (Sugarbaker 1994). The electrosurgical handpiece uses a ball tip that allows the tiles- sue surfaces beneath the peritonectomy to be contoured (Valleylab, Boulder, CO). The smooth surface is then able to be resurfaced by peritoneum (Fig. 3.1). Peritonectomies and visceral resections using traditional scissor and knife dissection wiU unnecessarily disseminate a large number of tumor cells within the abdomen. 

High-voltage electrosurgery leaves a margin of heat necrosis that is devoid of viable malignant cells. Not only does electroporation of tumor and normal tissue at the margins of resection minimize the likelihood of persistent disease, but also it minimizes blood loss. In the absence of Electrosurgery, profuse bleeding of stripped peritoneal surfaces can occur.

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