Cytoreductive surgery is the top surgical option for peritoneal mesothelioma patients. Combining it with heated intraperitoneal chemotherapy (HIPEC) has prolonged many American lives.
However, cytoreduction has a mixed reputation. Some researchers and specialists cite morbidity and mortality statistics associated with the surgery, which can involve numerous complications for the patient.
As frequently happens in the medical industry, time leads to evolution and improvement. A study published earlier in 2019 indicates cytoreduction for the cancer may be safer than thought.
What Cytoreduction for Mesothelioma Involves
Cytoreduction is defined on the Moffitt Cancer Center website as “debulking,” which is the removal of as much visible cancer cells as possible. Surgeons use this procedure to treat numerous types of cancer, notably ones that form or metastasize near the peritoneal cavity.
Cytoreduction for peritoneal mesothelioma involves removing the tumors from the peritoneum, the thin membrane surrounding the abdomen. This process may involve removing part of the peritoneum, which is where peritoneal mesothelioma forms and why it’s a target for the surgery.
For peritoneal mesothelioma, cytoreduction is more useful when combined with HIPEC. Mesothelioma tumors are microscopic, often challenging to locate. While the debulking process may remove a vast majority of the mutated cells, some remnants may stay hidden. Leaving behind mesothelioma cells leaves open the possibility for recurrence of the cancer.
HIPEC occurs now following cytoreduction. Once the surgeon removes as many tumors as they can, liquid chemo is administered directly into the patient’s abdominal cavity. Surgeons hope the chemotherapy eradicates most or all of the remaining tumors and reduces the chance of recurrence.
According to numerous studies, cytoreduction with HIPEC has increased patient survival. Five-year survival rates are anywhere from 40% to 50%, and most people live for at least three years following their surgery. Considering how aggressive mesothelioma is — the disease can end a person’s life within a year — these figures are outstanding.
Complications With Cytoreduction
Most surgeries have a risk associated with them. However, cytoreduction is considered so due to the volume of complications someone may endure.
According to an article published in the Indian Journal of Surgical Oncology, there are numerous types of issues associated with cytoreduction. For starters, the surgery plus HIPEC could cause patients to experience gastrointestinal problems. Small bowel perforations and anastomotic leaks are two of the most common, and others include intraperitoneal abscesses, pancreatic fistulas and gastric stasis.
Pleural effusions, postoperative infections and pneumonia are additional complications often linked to cytoreduction.
New Study Reveals Cytoreduction as Safe
Researchers from the University of Nebraska-Omaha Medical Center set out to investigate whether the concerns are warranted. Led by Dr. Jason Foster, the team analyzed more than 34,000 surgery cases involving five types of “high-risk” procedures. They looked at 1,822 cases of cytoreduction with HIPEC and compared the safety of that operation to the other four risky ones:
- Trisegmental hepatectomy (a type of surgery that removes all or part of the liver)
- Right lobe hepatectomy (a type of surgery that removes all or part of the liver)
- Pancreaticoduodenectomy (surgery to remove cancer from the pancreas)
- Esophagectomy (surgery to remove all or part of the esophagus)
The study, which was published in the Journal of the American Medical Association, stated that the perception around cytoreduction with HIPEC has limited referrals and clinical trial development. This effect may have restricted people from receiving the treatment they desperately needed.
So how did cytoreduction with HIPEC do compared to the other four surgeries? The 30-day mortality rate was 1.1%, much lower than the 2.5% to 3.9% for the other four. Cytoreduction with HIPEC also had the lowest rates for shared infections. The researchers wrote in the article that cytoreduction and HIPEC’s mortality risk was “almost 50% to 75% lower than other advanced oncology surgical procedures.”
In conclusion, the team stated that the results “provide objective data to dispel the misperception of morbidity and mortality concerns surrounding (the operation),” and concerns not specific to the patient shouldn’t restrict referrals for cytoreduction with HIPEC.
(Editor’s Note: For a mesothelioma specialist’s opinion on cytoreduction with HIPEC, listen to our podcast in the player below, or by clicking this link)
Surgical Options for Mesothelioma Patients
Cytoreduction with HIPEC is the primary curative surgery for peritoneal mesothelioma patients. Those with pleural mesothelioma have multiple options: extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D). However, which procedure a patient has often is based on how advanced their disease is.
If you have any type of mesothelioma, our patient advocates can give insight into your treatment options. You might be a candidate for cytoreduction with HIPEC, EPP or P/D, and the only way to find out is by connecting with a mesothelioma specialist. Email our patient advocate and registered nurse, Jenna Campagna, at firstname.lastname@example.org to begin the process.
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- CRS/HIPEC safety concerns may be outdated. MDedge. Retrieved from: https://www.mdedge.com/hematology-oncology/article/192729/gynecologic-cancer/crs/hipec-safety-concerns-may-be-outdated. Accessed: 07/29/19.
- Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: a systematic review and meta-analysis. The Annals of Surgical Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/25124472. Accessed: 07/29/19.
- Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases. Journal of Surgical Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/31309588. Accessed: 07/29/19.
- Debulking Cytoreductive Surgery for Ovarian Cancer. Moffitt Cancer Center. Retrieved from: https://moffitt.org/cancers/ovarian-cancer/debulking-cytoreductive-surgery/. Accessed: 07/29/19.
- Complications of Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases. Indian Journal of Surgical Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818615/. Accessed: 07/30/19.