People with mesothelioma cancer have just a few universally approved treatment options. Not long ago, they had even fewer.

Extrapleural pneumonectomy was the lone surgical option for years. Peritoneal mesothelioma patients had a more invasive and prolonged form of cytoreduction surgery than they do today. When surgery was not an option, patients received systemic chemotherapy (through an IV). In most cases, the life expectancy only improved by a few months thanks to chemotherapy treatment.

What changed about mesothelioma treatment? Many aspects did, but the emergence of “hot chemotherapy” might be the most notable one.

The use of hot chemotherapy (also called “hyperthermic chemotherapy”) has increased the effectiveness of peritoneal mesothelioma surgery and operations for pleural mesothelioma. Pumping the liquid chemotherapy drugs directly into the abdomen or thorax is improving the survival rates for patients after surgery and phasing out the necessity of more encroaching procedures.

Mesothelioma Guide has a breakdown of everything to know about hot chemotherapy, a type of chemotherapy treatment that is changing how doctors, researchers and patients view mesothelioma cancer survival.


What Is Hot Chemotherapy?

Hot chemotherapy is a type of cancer treatment involving heated, liquid chemotherapy. Doctors use a cocktail of hot chemotherapy drugs to bathe the diseased region of the body, such as the abdominal cavity (peritoneal mesothelioma) or thoracic cavity (pleural mesothelioma).

What’s most interesting about hot chemotherapy is how doctors deliver the treatment. Traditional chemotherapy is given through an IV, and it travels from the IV into the bloodstream and then to the diseased area. Traditional chemotherapy can kill healthy blood cells or tissue cells along the way.

Hot chemotherapy is delivered through ports inserted into the abdomen or chest. These ports give doctors direct access to the diseased area, such as the cavity where mesothelioma cancer exists. The medical team can funnel the liquid chemotherapy through the ports and directly into the target site. This method avoids chemotherapy in the bloodstream in other areas of the body, and it avoids killing healthy blood cells and healthy tissue cells.


When Is Hot Chemotherapy Delivered to Mesothelioma Patients?

Another interesting aspect of hot chemotherapy is when it’s given to patients. Traditional chemotherapy happens separately of any other treatment for cancer. Hot chemotherapy usually happens during surgery for cancers like mesothelioma.

Hot chemotherapy given during surgery is called heated intraoperative chemotherapy (HIOC). There are two types of HIOC for mesothelioma:

  • HITHOC (heated intrathoracic chemotherapy)
  • HIPEC (heated intraperitoneal chemotherapy)

Once the main tumors have been removed during either peritoneal mesothelioma surgery or pleural mesothelioma surgery, doctors add the ports and deliver hot chemotherapy. The objective is to wash the abdominal cavity or thoracic cavity in the hot chemo and destroy any leftover mesothelioma cells not found or taken out during surgery.


What Other Types of Hot Chemotherapy Treat Mesothelioma?

Aside from HIOC for mesothelioma, there are two main uses of hot chemotherapy after surgery. These two uses are primarily for peritoneal mesothelioma and haven’t been tested yet for pleural mesothelioma.

The two hot chemotherapy types after mesothelioma surgery are EPIC and NIPEC:

  • EPIC stands for “early postoperative intraperitoneal chemotherapy.” Doctors leave ports in the chest and give the patient postoperative hot chemotherapy a few days or weeks after surgery.
  • NIPEC stands for “normothermic intraperitoneal chemotherapy.” Doctors deliver hot chemotherapy multiple times after surgery to reduce the chance of remission (cancer returning). NIPEC usually lasts for a few weeks or months after surgery.

Now that we’ve explained what hot chemotherapy is, the different types and uses, and how it applies to mesothelioma, we can examine the impact of heated chemo on mesothelioma treatment as a whole. First, though, let’s discuss the background of the main mesothelioma surgery treatment options.


Extrapleural Pneumonectomy for Pleural Mesothelioma

Extrapleural pneumonectomy (EPP) is the most invasive mesothelioma surgery and was one of the first procedures available to pleural mesothelioma patients. The first cited use of EPP, in an article published in the Annals of Thoracic Surgery, was in 1958. For the next half-century, this procedure was one of the most often-used treatment approaches for patients with early stage pleural mesothelioma.

The procedure involves removing numerous areas of the body, along with an organ:

  • The protective membrane between the chest and lung cavity, which is known as pleura and where pleural mesothelioma forms
  • Part of the pericardium, a protective lining around the heart
  • Part of the diaphragm
  • The lung nearest to where mesothelioma formed

Removing an entire lung is an unappealing aspect of EPP. However, pleural mesothelioma patients have a new option.

extrapleural pneumonectomy for pleural mesothelioma


The Rise of Pleurectomy With Decortication for Pleural Mesothelioma

In the mid-1990s, specialists at the University of California Los Angeles Medical Center began developing a new surgery for pleural mesothelioma. The surgery, called pleurectomy with decortication (P/D), spares the lung and focus solely on the pleura, which is the thin tissue layer where mesothelioma forms.

Pleurectomy removes part of the pleura (the outer tissue lining). The decortication portion of the procedure removes the inner tissue lining, which is next to the lungs. The hope is removing the pleura will strip any tumors and diseased cells off of the lungs, which keeps the organs safe and prevents them being removed.

In recent years, doctors have developed a radical or “extended” P/D surgery, which removes the diaphragm and pericardium (tissue layer around the heart) in addition to the pleura. The survival rates for extended P/D are even better than normal P/D.

The surgery gave people an alternative for taking out mesothelioma cancer, and more doctors are supporting P/D over EPP in recent years.

From 1995-2012, EPP was used in the majority of mesothelioma surgery cases:

  • EPP used in 53.4% of surgery cases
  • P/D used in 46.6% of surgery cases

From 2007-2017, P/D became the preferred surgery in a landslide:

  • P/D used in 81.3% of surgery cases
  • EPP used in 18.7% of surgery cases

P/D is considered safer than extrapleural pneumonectomy — one study reported a mortality rate of 3.5% for P/D and 7% for EPP — but P/D surgery is only for early stage patients (stage 1 or stage 2). If the cancer hasn’t spread to the nearby lung — or only just started affecting the organ — then patients theoretically could keep their lung and remove the tumors.

If a patient’s lung is overrun with mesothelioma tumors, then EPP is likely the only option.

Or, should we say, it was the only option.

pleurectomy with decortication for pleural mesothelioma


How Heated Chemotherapy Works for Peritoneal Mesothelioma

Peritoneal mesothelioma develops in the peritoneum, which is similar to the pleura. The peritoneum is a tissue lining that surrounds and protects the abdominal cavity. The peritoneum is also where peritoneal mesothelioma starts, and the cancer usually spreads into the abdominal cavity, which includes many important organs (gallbladder, large and small intestines, pancreas, kidneys and more).

The top surgery for peritoneal mesothelioma is called cytoreduction or cytoreductive surgery. Doctors usually remove part or all of the peritoneum to take out all mesothelioma tumors from the area. They also take out the omentum (which is a tissue layer attached to the peritoneum), spleen, gallbladder, and part of the large or small intestine.

However, the microscopic tumors may metastasize into the abdominal cavity and affect organs like the kidneys and pancreas. Removing these organs is not preferred, and some organs cannot be taken out at all.

Therefore, how can surgeons improve their patient’s post-surgery prognosis and remove as many tumors as possible? Peritoneal mesothelioma specialists faced these questions.

The answer to them was — and still is — heated chemotherapy.

According to the Annals of Translational Medicine, HIPEC joined cytoreductive surgery in the mid-1980s as a front-line treatment for peritoneal mesothelioma. Rather than the chemotherapy drugs delivered intravenously into the patient’s blood, they are administered in liquid form directly into the abdominal cavity.

Numerous studies have reported excellent results from using HIPEC with cytoreductive surgery. Patients who undergo this procedure have a median survival of around 60 months, and the 5-year survival rate for them is close to 50%. By comparison, patients who simply undergo chemotherapy, radiation or a less-invasive surgery have a much shorter life expectancy.

Now, more than three decades later, pleural mesothelioma specialists are implementing heated chemotherapy to their surgical practices.

cytoreduction and HIPEC for peritoneal mesothelioma


Combining Heated Chemotherapy and Pleurectomy With Decortication

The Journal of Thoracic Disease published the results of a study that appeared on the U.S. National Library of Medicine website in May 2019. The study analyzed 71 people who had localized pleural mesothelioma (stage 1 or stage 2 mesothelioma) and underwent surgery between 2009 and 2013.

The patients underwent P/D, the less-invasive option for treating pleural mesothelioma. At the end of the operation, they received HITHOC (heated intrathoracic chemotherapy0. This region of the body includes the lung cavity, the since-removed pleura and the diaphragm. The surgeons used cisplatin and doxorubicin as the chemotherapy drugs.

People who had a complete macroscopic resection — meaning the surgeons also removed the diaphragm and/or pericardium — had great outcomes. Their median survival time following surgery was around 28 months, more than double the median of 13 months for patients who did not undergo complete resection.

Other studies followed up on this success and found similar results:

  • In one study, P/D plus HITHOC led to a remarkable median survival of 42 months.
  • In another study, extended P/D plus HITHOC led to a median survival of 28 months.

heated chemotherapy in the chest cavity


What Does This Mean for EPP’s Future?

What if pairing P/D with heated chemotherapy could help patients with stage 2 or stage 3 pleural mesothelioma?

EPP remains most useful when specialists know the patient’s mesothelioma has spread to the nearby lung. This level of the disease is not stage 1 or “localized.” But could hyperthermic chemotherapy delivered directly into the thorax attack tumors that have spread to the lungs, diaphragm and other organs?

In essence, would heated chemotherapy lessen the necessity for EPP in treating pleural mesothelioma?

From a surface-level standpoint, this thought process makes sense. P/D removes the pleura and other infected tissue. The chemotherapy drugs attack the cells that spread to other thoracic areas.

At least for the next few years, EPP remains a featured surgical option for pleural mesothelioma patients. If tumors have reached the nearby lung, there’s no quicker way to removing the cancer than merely taking out that organ and moving forward.

However, heated chemotherapy as a tag team partner with P/D is opening up the possibility of using this combination for late-stage cases of mesothelioma. If this type of thought process continues among mesothelioma doctors, then EPP surgery might be used only in specific cases and not as often as it once was. The trend towards P/D surgery is already happening.

If you have mesothelioma and want to learn your treatment options or are considering which route to take, contact our patient advocate team. Karen Ritter, a registered nurse, is the top medical resource for people afflicted with this cancer. She can connect you with the top mesothelioma specialists in the country and provide extra insight into how treatment works. Email her at for additional information on surgery, chemotherapy and more.


Frequently Asked Questions About Cancer and the Immune System

  • What happens in chemotherapy?

    Chemotherapy is a treatment that uses drugs to kill cancer cells. The drugs are usually administered intravenously and travel throughout the body to attack cancer cells. However, chemotherapy can also affect healthy cells, which can lead to side effects such as nausea, hair loss, and fatigue.
  • What is a lung decortication?

    Lung decortication is a surgical procedure that involves removing the lining of the lung (pleura) in order to remove mesothelioma tumors and relieve symptoms caused by mesothelioma or other lung diseases. It may also be used to help diagnose and stage these conditions.
  • What is a chemo wash?

    A chemo wash, also known as HITHOC or HIPEC (Heated Intrathoracic or Intraperitoneal chemotherapy) is a procedure used to treat mesothelioma that involves administering chemotherapy drugs directly into the chest or abdominal cavity to kill cancer cells. This procedure is performed in combination with surgery to help prevent the cancer from returning.
  • What type of chemo is used for lung cancer?

    There are several types of chemotherapy drugs used for lung cancer, including cisplatin, carboplatin, paclitaxel, gemcitabine, docetaxel, and vinorelbine. The specific type of chemotherapy prescribed depends on the stage and type of lung cancer, as well as the patient's individual health and treatment goals.
  • What are the success rates of chemotherapy?

    The success rates of chemotherapy for mesothelioma vary depending on the stage of the cancer and individual patient factors. However, studies have shown that chemotherapy can extend a patient's overall survival and improve their quality of life. Chemotherapy can also be used in combination with other treatments, such as surgery and radiation therapy, to increase effectiveness. It is important to discuss your specific situation and potential outcomes with your doctor.
  • What is stage 3c peritoneal cancer?

    Stage 3C peritoneal cancer refers to cancer that has spread beyond the peritoneal cavity to nearby lymph nodes and/or organs. It is an advanced stage of cancer and may require aggressive treatment such as surgery, chemotherapy, and radiation therapy.
  • What is heated chemotherapy?

    Heated chemotherapy, also known as hyperthermic intraperitoneal chemotherapy (HIPEC) or hyperthermic intrathoracic chemotherapy (HITHOC), is a procedure used to treat mesothelioma. It involves administering a heated chemotherapy solution through the abdominal or chest cavity with the goal of killing any cancer cells remaining after surgery. It is commonly used for peritoneal and pleural mesothelioma, cancer that affects the lining of the abdominal or chest cavity.
  • When to start chemo after surgery?

    The timing of chemotherapy after surgery for mesothelioma will vary based on each individual case. However, in general, chemotherapy may be started as soon as two to four weeks after surgery to help prevent the cancer from returning. It is important to discuss the best timing for chemotherapy with your medical team.
  • Why is the diaphragm considered an organ?

    The diaphragm is considered an organ because it is a muscular structure that separates the chest cavity from the abdominal cavity and plays a crucial role in the respiratory process by contracting and relaxing to control breathing.
  • How is chemo administered?

    Chemotherapy can be administered through intravenous (IV) infusion, injection, pill, or capsule form. The method of administration is determined based on the type and stage of cancer being treated.
  • How long does it take for chemo to leave the body?

    The amount of time it takes for chemotherapy to leave the body varies depending on the type of drugs used and the individual's metabolism. Generally, chemotherapy drugs are eliminated from the body within a few days to a few weeks after treatment. However, some chemotherapy drugs can remain in the body for several months. It is important to discuss any concerns about chemotherapy with your doctor.
  • How is cisplatin administered?

    Cisplatin is typically administered through an IV (intravenously) in a hospital or clinical setting. It can also be given via intraperitoneal infusion for certain types of cancers.
  • How does chemo affect the body?

    Chemotherapy for mesothelioma can cause a range of side effects, including fatigue, nausea, vomiting, and decreased appetite. However, the treatment can also help shrink tumors and improve symptoms, leading to an improved quality of life for patients. The specific effects of chemotherapy on the body depend on the type of drugs used, the dosage, and the individual patient's health status.

    Sources & Author

    1. Pleurectomy Decortication in the Treatment of Malignant Pleural Mesothelioma. Annals of Surgery. Retrieved from: Accessed: 12/07/2020.
    2. Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D). Annals of Translational Medicine. Retrieved from: Accessed: 01/03/2023.
Devin Golden

About the Writer, Devin Golden

Devin Golden is a content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.

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    Sources & Author

Picture of Devin Golden

About the Writer, Devin Golden

Devin Golden is the content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.