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Primary peritoneal mesothelioma: How aggressive should we be?

SOURCE: ASCO, 2004 Annual Meeting

D. M. Labow, D. G. Coit, D. Kelsen, J. Shia, S. Freeman, M. R. Weiser; Memorial Sloan-Kettering Cancer Center, New York, NY

Background: Primary peritoneal mesothelioma is a rare disease with an unpredictable clinical course. This has led to a variety of treatment options, ranging from minimal debulking, debulking with adjuvant intraperitoneal (i.p.) chemotherapy to aggressive debulking with peritonectomy with hyperthermic intra-operative i.p. perfusion. It is unclear whether outcome is dependent on treatment, patient selection or tumor biology.

Methods: A retrospective review of all patients with primary peritoneal mesothelioma treated at a single institution between 1/1/82-1/1/02 was performed. Patient, tumor and treatment variables were reviewed.

Results: Thirty-seven pts. with primary peritoneal mesothelioma were identified. Patients with pleural mesothelioma with peritoneal extension were excluded. Median follow-up was 49 months (range 3-97mos.) There were 15 male and 22 female pts. with a median age of 56 years. All pts. were explored with the pre-operative goal of maximal cytoreduction with minimal sacrifice of adjacent organs. Total peritonectomy was not performed. The adequacy of debulking was grouped into 5 categories ranging from 0-25% debulked (12 pts.), 26-50% (5 pts.), 51%-75% (1 pt.), 76%-99% (13 pts.) or complete (6 pts.) The overall complication rate was 30% with 3 post-operative deaths. Thirty pts. (81%) were treated with adjuvant chemotherapy: 18 pts. received only i.p. chemotherapy, 7 received both i.p. and i.v. chemotherapy and 5 received i.v. chemotherapy only (7 unknown). The most common i.p. regimen was combined cisplatin/mitomycin C (17 pts.) (Cancer Res Clin Oncol 1992, 118:547-50). The median overall survival was 58 months. Twenty-seven pts. felt relief of symptoms as manifest by decreased pain and/or decreased ascites. Optimally debulked (76-99% or complete) patients showed improved long-term survival as compared to those who were sub-optimally debulked (p<0.001). The addition of i.p. chemotherapy was also associated with significantly improved survival (p=0.009).

Conclusions: Mesothelioma is a rare but lethal disease. Long-term survival can be realized in patients that undergo optimal debulking, without peritonectomy, and receive adjuvant i.p. chemotherapy.