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Cytoreductive Surgery and Intraoperative Hyperthermic Intrathoracic Chemotherapy in Patients With Malignant Pleural Mesothelioma or Pleural Metastases of Thymoma^*

^* From the Departments of Surgical Oncology (Drs. de Bree, van Ruth, Rutgers, Witkamp, and Zoetmulder) and Thoracic Oncology (Drs. Baas and van Zandwick), the Netherlands Cancer Institute, Amsterdam, the Netherlands.

Correspondence to: Frans A. N. Zoetmulder, MD, PhD, Department of Surgical Oncology, the Netherlands Cancer Institute, (Antoni van Leeuwenhoek Huis), Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands; e-mail: fzoet{at}nki.nl

Study objectives: No established curative treatment is available for pleural thymoma metastases and malignant pleural mesothelioma (MPM). Recently, peritoneal malignancies have been treated by cytoreductive surgery and intraoperative hyperthermic intracavitary perfusion chemotherapy (HIPEC). We investigated the feasibility and safety of this multimodality treatment in the thoracic cavity.

Design: Patients with pleural thymoma metastases or early-stage MPM were enrolled in a feasibility study. Morbidity, recurrence, and survival rates were recorded.

Setting: The Netherlands Cancer Institute.

Patients: Three patients with pleural thymoma metastases and 11 patients with pleural mesothelioma were treated.

Interventions: Cytoreductive surgery and intraoperative hyperthermic intrathoracic perfusion chemotherapy (HITHOC) with cisplatin and adriamycin were performed. The mesothelioma patients received adjuvant radiotherapy on the thoracotomy wound and drainage tracts.

Measurements and results: Morbidity and mortality rates were 47% and 0%, respectively. Reoperation was necessary in four cases. Severe chemotherapy-related complications were not observed. A solitary mediastinal and a contralateral pleural thymoma recurrence were successfully treated by radiotherapy and a contralateral HITHOC procedure. All thymoma patients were alive and free of disease after a mean follow-up period of 18 months. After a mean follow-up period of 7.4 months, nine mesothelioma patients are alive. Two mesothelioma patients died of contralateral pleural and peritoneal recurrent disease, while one patient is alive with locoregional recurrence.

Conclusions: Cytoreductive surgery and HITHOC with cisplatin and adriamycin is feasible in patients with pleural thymoma metastases and early-stage MPM, and is associated with acceptable morbidity rates. Early data on locoregional disease control are encouraging, and a phase II study will be conducted.

Key Words: cytoreductive • hyperthermia • intrapleural chemotherapy • intrathoracic chemotherapy • malignant mesothelioma • pleural malignancy • surgery • thymoma • thymic carcinoma

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