The same is true for mesothelioma as is for any type of cancer: The quickest way to remove the fast-growing disease is through surgery. If the patient can withstand an aggressive operation and possibly having large chunks of tissue – or even an organ – removed, then they’ll usually survive much longer than if they went the route of chemotherapy or other cancer-fighting drugs.

For peritoneal mesothelioma, HIPEC surgery with cytoreduction is the top operation. HIPEC is the acronym for heated intraperitoneal chemotherapy. The surgery can add multiple years of survival onto patients’ lives following their diagnosis.

If having one surgery can help, then what about having two operations?

Wake Forest Baptist Cancer Center, one of the top hospitals in the world for peritoneal mesothelioma treatment, examined the possibility of performing the same surgery multiple times for peritoneal diseases limited to the peritoneal cavity. Peritoneal mesothelioma develops in a thin membrane, called the peritoneum or peritoneal cavity, that surrounds the abdominal cavity.

In a 30-year time span, Wake Forest Baptist Cancer Center had 156 cases of repeat cytoreductive surgery with HIPEC. The results point to a definite benefit to patients who are willing and able to have multiple surgeries.


What Is HIPEC Surgery?

Cytoreductive surgery with HIPEC is a two-part procedure for peritoneal malignancies (cancers). Cytoreduction is the manual removal of all visible tumors. Many hospitals also perform a peritonectomy, which is removal of the peritoneal lining by stripping it off of the abdominal cavity. Ideally, a peritonectomy strips away any tumors along the lining and exterior of the abdominal cavity.

Doctors usually remove the omentum and other at-risk, non-vital organs, such as the spleen.

HIPEC, or heated intraperitoneal chemotherapy, is an intraoperative form of cancer treatment. Doctors use this method during surgery, which is why many call it the “HIPEC surgery.”

Doctors insert ports or catheters into the patient’s abdomen. These ports funnel liquid chemotherapy drugs into the abdominal cavity. The hyperthermic therapeutics bathe the abdominal cavity, including the peritoneum, in tumor-burning drugs.

The chemotherapy drug used is cisplatin. It’s heated to 103 degrees Fahrenheit and the surgical team rocks the patient back and forth on the bed. This act washes the abdomen in chemotherapy drugs.

According to MD Anderson Cancer Center, close to 90% of the liquid cisplatin chemotherapy remains in the abdominal cavity to keep the rest of the body’s healthy tissues safe.

The intent is to wash out and kill any tiny cancer cells that have evaded the surgical team’s eyes and are hiding in small crevices inside the body. For peritoneal mesothelioma, tumors escaping resection happens often, which is why HIPEC is a necessary component of cytoreductive surgery.


Issue of Peritoneal Mesothelioma Recurrence

The issue is even HIPEC doesn’t kill every single tumor, leaving a chance of recurrence (the cancer returning and re-growing). Recurrence rates are high for peritoneal mesothelioma due to the biological nature of tumors replicating into smaller individual tumors rather than just growing as one large mass.

So the independent tumors often are distanced enough from one another that a few survive surgery and treatment. Even though these tumors are tiny and nearly undetectable, they can grow and replicate into more tumors, becoming the source of peritoneal mesothelioma again becoming a major health concern for the patient.

Unlike pleural mesothelioma – the other type of mesothelioma, forming near the lungs – peritoneal mesothelioma is treatable with multiple surgeries. Since cytoreduction can be limited to just manual removal of diseased (cancerous) tissue, doctors can revisit the surgery as often as the patient’s health allows. No lining or organs need to be resected.

Pleural mesothelioma is different because of the proximity of the lungs to the tumors. Pleural mesothelioma’s two surgeries, pleurectomy with decortication and extrapleural pneumonectomy, involve removing large chunks of tumors, muscles and sometimes organs.

Extrapleural pneumonectomy is removal of one lung, and doctors cannot take out the other, eliminating the possibility of two extrapleural pneumonectomy surgeries. Pleurectomy/decortication is stripping away of the pleural lining and also cannot be performed a second time as any re-growth of cells usually involves the lungs.


Benefit of a Second HIPEC Surgery

Wake Forest Baptist Cancer Center doctors reported a median survival of 2.5 years (30 months) after one cytoreductive surgery with HIPEC. This statistic incorporated cases of peritoneal mesothelioma, along with appendix cancer, colorectal cancer and other malignancies near the peritoneal cavity.

In past studies involving just peritoneal mesothelioma, the Wake Forest surgery team reported a median survival of 53 months (4.5 years) after cytoreduction with HIPEC surgery. The five-year survival rate was an impressive 50%, and this rate included mostly one-surgery cases.

The patients undergoing multiple cytoreductive surgeries with HIPEC procedures had a median survival of 10.7 years. The longevity of their survival is due to addressing recurrence of tumors after the initial operation.


Other Options Besides Surgery for Peritoneal Mesothelioma

If surgery isn’t possible, what are the other options for peritoneal mesothelioma? Well, the top two options are chemotherapy and immunotherapy. Neither has the same survival benefit as surgery.

Chemotherapy, specifically the therapy delivered through an IV into the bloodstream, can stall the growth of tumors for a few months. One study reported a median survival of 17 months for peritoneal mesothelioma patients who receive only chemotherapy.

The chemotherapy drugs used are pemetrexed (Alimta) and cisplatin. This platinum combination led to a 41% disease response rate in one study for peritoneal mesothelioma. While this response helps patients for a few months, it’s not effective on the level of HIPEC and cytoreduction.

The publication Cancers reported data from the SEER database on peritoneal mesothelioma survival by type of treatment. The three options assessed were surgery, chemotherapy and radiation. Since radiation is rarely used for peritoneal mesothelioma, the comparison mainly lies between surgery and chemotherapy.

According to the data from 1,998 cases, surgery aids patients’ peritoneal mesothelioma life expectancy by a wide margin. The five-year survival rate for surgery cases was approximately 44%, which is an excellent number considering the aggressive and deadly nature of this disease. Chemotherapy only led to five-year survival in 18% of cases.

The issue is chemotherapy is much more likely an option than surgery. Chemotherapy was a primary element of treatment in approximately 50% of the 1,998 cases. Surgery was only used in 29% of cases.

Immunotherapy for Peritoneal Mesothelioma: Growing in Popularity

The other option is immunotherapy. The treatment was approved for pleural mesothelioma – Opdivo and Yervoy were approved by the U.S. Food and Drug Administration as a combination – but is in testing for peritoneal mesothelioma.

Doctors support immunotherapy for peritoneal mesothelioma but there is little data showing any survival benefit with Opdivo and Yervoy for the cancer. Even if immunotherapy leads to similar survival results, the median survival is 18 months. This pales in comparison to HIPEC and cytoreductive surgery, which often triples this amount in months.

Another option is the immunotherapy combination of atezolizumab and bevacizumab, which showed promise in a clinical trial a few years ago for peritoneal mesothelioma:

  • 80% one-year survival rate
  • 60% one-year rate for lack of disease progression
  • 17.6 months median progression-free survival

These are alternatives to surgery for patients with a more advanced peritoneal mesothelioma. Radiation, which is a therapy option for pleural mesothelioma, is rarely used for peritoneal mesothelioma due to the number of organs in the abdomen.


Wake Forest’s Peritoneal Mesothelioma Specialist

Dr. Edward Levine, the Chief of Surgical Oncology at Wake Forest Baptist Health, co-authored the study. He is the head of peritoneal mesothelioma treatment at Wake Forest Baptist Cancer Center.

He has previously talked about how peritoneal tumors often multiply to unknown quantities – and of the challenge to remove all of them in one surgical swoop.

“The spread through the peritoneal cavity is difficult to complete fully, especially in patients who were previously operated on,” Dr. Levine said. “… When you take the patient to the operating room, you’re going to find more tumors than you saw before most of the time.”

Dr. Levine and his team at Wake Forest see between one and two dozen peritoneal mesothelioma cases each year. Wake Forest Baptist Health has one of the highest-volume HIPEC programs along the Atlantic coast. The other two notable doctors in Wake Forest Baptist Cancer Center’s peritoneal mesothelioma care team are:

  • Dr. Konstantinos Votanopoulos, surgical oncologist
  • Dr. Paul Savage, medical oncologist

We at Mesothelioma Guide highly recommend Wake Forest Baptist Cancer Center for treatment, especially for people with peritoneal mesothelioma. Dr. Levine is an acclaimed surgeon with more than two decades of work at the hospital, which he joined in 1998.

If you want to learn more about cytoreduction surgery with HIPEC treatment, let lead patient advocate and registered nurse Karen Ritter know. Her email is and she can provide answers to any questions you have about peritoneal mesothelioma, including the best path for treatment and extending your life as much as possible.

    Sources & Author

    • Repeat Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Cancers with Peritoneal Metastasis: A 30-year Institutional Experience. Annals of Surgical Oncology. Retrieved from: Accessed: 03/22/2022.
Devin Goldan image

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.

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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.