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

For years, extrapleural pneumonectomy was the lone surgical option for pleural mesothelioma. Peritoneal mesothelioma patients had a more prolonged form of cytoreduction surgery than they do today. When surgery was not an option, patients were given intravenous chemotherapy. In most cases, the life expectancy only improved by a few months with systemic chemotherapy.

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

The HIPEC procedure is used to increase the effectiveness of cytoreduction. Heated chemotherapy is now being introduced for the treatment of pleural mesothelioma. Pumping the heated liquid chemotherapy directly into the abdomen or thoracic cavity in the operating room is improving the survival rates for all mesothelioma patients.

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


What Is Heated Chemotherapy?

Hot chemotherapy is a type of cancer treatment that uses a chemotherapy solution heated to a specific temperature and then put directly into the body cavities where mesothelioma develops. Doctors use the chemotherapy solution to coat the diseased region of the body, such as the abdominal cavity (peritoneal mesothelioma) or thoracic cavity (pleural mesothelioma) to kill cancer cells.

What’s most interesting about heated chemotherapy is how doctors deliver the treatment. Chemotherapy is typically given through an IV, and it travels into the bloodstream and then circulates throughout the body targeting cancer cells. The disadvantage of IV chemotherapy is that it can kill healthy and cancer cells. 

Heated chemotherapy is delivered through tubes inserted into the abdomen or chest. By performing this procedure during surgery, doctors are given direct access to where the cancer develops. The chemotherapy solution is pumped through the abdominal cavity or chest cavity. This method prevents high doses of chemotherapy from getting into the bloodstream, causes fewer side effects and prevents the killing of healthy blood and tissue cells.


When Is Hot Chemotherapy Delivered to Mesothelioma Patients?

Another interesting aspect of hyperthermic chemotherapy, or hot chemo, is when it’s given to patients. Traditional chemotherapy is a stand-alone treatment that is provided separately from any other treatments. HIPEC is performed at the end of surgery to remove the mesothelioma tumor.  

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

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

Surgical oncology doctors remove all visible tumors during cytoreductive or pleurectomy/decortication surgery. Before the completion of the surgeries, a HIPEC or HITHOC specialist will place catheters into the body cavity (abdomen or chest) and then deliver the heated chemotherapy drugs.

The patient will remain on the operating table for about 2 hours to ensure the chemotherapy solution lathers the cavity to ensure good coverage of the tissues and kills any remaining cancer cells not removed during the excision. The surgical table will move to rock the patient back and forth on the operating table so the chemotherapy can saturate all remaining cancer cells.


What Other Forms of Chemotherapy Are Used To Treat Mesothelioma?

Aside from HIOC for mesothelioma, there are two other ways chemotherapy is used after surgery. These two uses are primarily for peritoneal mesothelioma and haven’t been tested yet for pleural mesothelioma.

The two intraperitoneal chemotherapy methods used after cytoreductive 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 have explained how chemotherapy drugs are heated, the benefits of HIPEC and HITHOC, what makes this an effective treatment method, and how it is used to treat mesothelioma. Now let’s discuss the background of the surgical treatment options depending on the type of mesothelioma.


Extrapleural Pneumonectomy for Pleural Mesothelioma

Extrapleural pneumonectomy (EPP) is the most aggressive form of pleural mesothelioma surgery. It 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 the lung and surrounding diseased tissues:

  • The protective membrane between the chest and lung cavity, which is the 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 surgical procedure for the treatment of pleural mesothelioma. The surgery, called pleurectomy with decortication (P/D), spares the lung and focuses solely on removing the pleura, which is the thin tissue layer of the lung where mesothelioma forms.

Pleurectomy removes part of the pleura (the outer lining along the chest wall). The decortication portion of the procedure removes the inner lining, which is next to the lung. The hope is by removing the pleura that all visible tumors are removed off the surface of the lungs, which keeps the lung safe and intact.

In recent years, doctors have developed a radical or “extended” P/D surgery, which removes part of the diaphragm and the pericardium (tissue lining of 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, patients are evaluated for P/D surgery. 

If a patient’s mesothelioma cancer has spread inside or onto the lung surface, which is considered metastatic cancer, EPP might be a better 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 a tissue lining of the abdominal cavity. This cancer usually spreads within the abdomen, which contains many important organs (gallbladder, large and small intestines, pancreas, kidneys and more).

The top surgery for peritoneal mesothelioma is called cytoreductive surgery with HIPEC. The surgeon removes part or all of the peritoneum in an attempt to take out most if not all mesothelioma tumors. They also may remove the omentum (a fatty tissue layer covering the abdominal cavity), spleen, gallbladder, and part of the large or small intestines.

Microscopic cancerous cells may impact abdominal organs like the kidneys and pancreas but removal of these organs may not be advised or possible. 

How can surgeons improve their patients’ post-surgery prognosis and how can they remove as many tumors as possible? Mesothelioma specialists faced these questions.

The answer to them was — and still is — heated intraperitoneal chemoperfusion.

According to the Annals of Translational Medicine, surgery plus hyperthermic intraperitoneal chemotherapy was initiated in the mid-1980s as a front-line treatment for peritoneal mesothelioma. Rather than chemotherapy drugs being delivered intravenously into the patient’s blood, the HIPEC expert administers the liquid chemotherapy directly inside the abdomen.

Numerous studies have reported excellent results from using cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. 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 undergoing chemotherapy, radiation or a less aggressive surgery have a much shorter life expectancy. 

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

cytoreduction and HIPEC for peritoneal mesothelioma


Combining Heated Chemo 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 aggressive surgical option for treating pleural mesothelioma. At the end of the operation, they received HITHOC (heated intrathoracic chemotherapy). The HITHOC is placed into the chest cavity after removal of the pleura, part of the diaphragm and any diseased tissue in the area. The surgeons used cisplatin and doxorubicin as the chemotherapy drugs.

People who had a complete macroscopic resection — meaning the surgeons were able to remove all visible tumors, removal of 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


The Future of Extrapleural Pneumonectomy

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 chest attack tumors that have spread to the lungs, diaphragm and other organs?

In essence, could 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 diseased tissue. The chemotherapy drugs attack the cells that spread to other thoracic areas.

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

However, hot chemotherapy as a tag team partner with P/D is opening up the possibility of using this combination for late-stage cases of pleural 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 Hot Chemotherapy

  • 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.

    Sources & Author

Picture of 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.