An innovative long-term treatment plan for peritoneal mesothelioma has resulted in an astounding 75% 5-year survival rate.
Surgical oncologist, Dr. Paul Sugarbaker, spent decades developing this treatment protocol. He is known for pioneering cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), the most effective treatment for peritoneal mesothelioma.
Since HIPEC was invented, Dr. Sugarbaker has been working to improve the treatment. He has been extending patient’s life expectancy by experimenting with different drugs and protocols. Over time, his protocol has extended into a long-term treatment plan including three steps of chemotherapy treatments.
The Evolution of Cytoreduction with HIPEC
Cytoreduction involves the surgical removal of the peritoneum along with any visible tumors in the abdomen. It is followed by hyperthermic intraperitoneal chemotherapy (HIPEC) or bathing of the abdomen with heated chemotherapy. This procedure is often used on patients with local disease and absence of liver metastases.
The initial implementation of intraperitoneal chemotherapy after cytoreduction was criticized for its toxicity to healthy tissue and organs. Over the past 20 years, Dr. Sugarbaker and other surgical oncologists took that as a challenge to perfect the procedure by implementing new protocols.
The only FDA approved drug used for intraperitoneal administration is the chemotherapeutic drug, cyclophosphamide. However, specialists have found that it is less effective in intraperitoneal use and more valuable in intravenous use.
Another chemotherapeutic drug, doxorubicin, had a very high response rate in a clinical trial. However, it needed to be dosed correctly. Dr. Sugarbaker took it into his own hands to discover the correct dosage. He also realized doxorubicin has a low chance of systemic complications as it passes quickly through the liver. It is also compatible with other chemotherapeutic agents, like cisplatin.
The combined intraperitoneal use of doxorubicin with cisplatin was favored by Dr. Sugarbaker. Once the chemotherapeutic agents were combined and heated, they killed off any remaining cancer cells after cytoreductive surgery.42 patients who underwent cytoreductive surgery with HIPEC had an overall 44% 5-year survival rate.
Dr. Sugarbaker was determined to improve these results. Peritoneal mesothelioma patients across the country were averaging a 2-year survival rate. This warranted further investigational studies, including adding two more procedures to the protocol.
Early Postoperative Intraperitoneal Chemotherapy
Early postoperative intraperitoneal chemotherapy (EPIC) is the second step in Dr. Sugarbaker’s new protocol. It is similar to HIPEC but the chemotherapy is not heated. It is administered the same way but for 5 days postoperatively, after a patient has already undergone cytoreductive surgery with HIPEC.
The chemotherapeutic agent used for this procedure is paclitaxel. Paclitaxel has a high molecular weight allowing it to penetrate the peritoneal surface better. It has shown to help peritoneal mesothelioma patients who also have debilitating fluid build up or ascites.59 patients who underwent cytoreductive surgery with HIPEC and EPIC had an overall 52% 5-year survival rate.
Normothermic Intraperitoneal Chemotherapy
To preserve a patient’s surgical response, a third step in the protocol was implemented. It is similar to EPIC but involves multiple cycles of treatment. Patients were given two different treatments in the protocol, intraperitoneal paclitaxel only or intraperitoneal pemetrexed plus intravenous (IV) cisplatin. Since these adjuvant chemotherapy procedures are given at normal temperature, the procedure is called normothermic intraperitoneal chemotherapy (NIPEC).29 patients who underwent cytoreductive surgery with HIPEC, EPIC, and NIPEC had an overall 75% 5-year survival rate.
From these results, it is evident that long term regional chemotherapy to the peritoneum can extend a patient’s life. Combining cytoreduction with HIPEC, EPIC, and lastly NIPEC has given mesothelioma patients more hope. Dr. Sugarbaker and other surgical oncologists will continue to investigate treatment plans for peritoneal mesothelioma.
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- Update on Chemotherapeutic Agents Utilized for Perioperative Intraperitoneal Chemotherapy. The Oncologist. Retrieved from: http://theoncologist.alphamedpress.org/content/10/2/112.full. Accessed: 2/23/17.
- Long-term regional chemotherapy for patients with epithelial malignant peritoneal mesothelioma results in improved survival. European Journal of Surgical Oncology. Retrieved from: http://www.ejso.com/article/S0748-7983(17)30059-8/abstract. Accessed: 2/23/17.
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