Cytoreductive Surgery Plus Perioperative Chemotherapy

Coping with mesothelioma is a very tough ordeal, especially since no two cases of this deadly asbestos cancer are the same. Every patient’s mesothelioma treatment regimen must be tailor-made to suit the individual and often includes a combination approach to achieve best results.
Top mesothelioma doctors and specialists agree that the best currently available form of treatment for this asbestos related disease is a multimodal approach – or combination therapy – which involves some type of surgery in addition to chemotherapy and possibly radiation treatments.

One of the most popular multimodal approaches is to couple cytoreductive surgery with perioperative chemotherapy.

What is Cytoreductive Surgery?

Cytoreductive surgery is a procedure in which a mesothelioma surgeon removes or attempts to remove all or most of a mesothelioma tumor. Depending on where the tumors are located and what type of surgery is decided upon, the procedure can include opening of the chest cavity or abdomen and removal of large portions of pleural or peritoneal tissue.

Surgeons often use electrically charged or heated cutting tools to cauterize wounds. This minimizes bleeding and decreases the appearance of scar tissue – which mesothelioma “cancer seeds” can hide in.

In rare cases, surgery may be possible through less invasive procedures with the use of endoscopes and specialized miniature surgical tools, but this is not often the case with mesothelioma. Unfortunately, malignant mesothelioma is often diffuse – meaning that it spreads throughout the abdominal cavity or chest cavity. Surgeons must be able to get into the patient’s body and visually inspect for tumor tissue, and these types of surgeries are in-patient procedures that require general anesthetics.

What is Perioperative Chemotherapy?

Perioperative chemotherapy is a form of drug therapy that is administered after a surgical procedure such as cytoreductive surgery but before the patient’s wounds have been closed. This allows surgical oncologists to administer chemotherapy drugs immediately after tumor removal to better increase the chances of killing all the cancer. The surgery takes care of visible tumors and the chemotherapy does its best to kill the invisible “cancer seeds” that can cause recurrence or metastasis.

There are multiple forms of perioperative chemotherapy for mesothelioma including:

• “Open” meaning the chemotherapy drugs are administered while the patients is still on the operating table and their surgical wound has yet to be sewn shut.
• “Closed” meaning the patient is still on the table but the wounds have been closed and the chemo is delivered through catheters.
• “Hyperthermic” meaning heated chemotherapy solutions are used to increase effectiveness. Hyperthermic chemotherapy can be delivered using either the open or closed methods.

Benefits of Perioperative Chemotherapy

In many cases, perioperative chemotherapy is preferable to and more effective than systemic chemotherapy, which is typically administered weeks after any surgical procedure is performed. Delivery of chemotherapy drugs during surgery has the advantage of accessing portions of the body quickly, before scar tissue forms and hides potential cancer cells.

Perioperative chemotherapy is also preferable because it shares the same risk profile as traditional chemotherapy. Multiple studies have found that the two types of mesothelioma treatments have very similar rates of adverse reactions and share a similar list of side effects.  In addition, this type of immediate chemotherapy can be used to prevent “wound hijacking, " decreasing the chance of tumor growth within the surgical wounds of the mesothelioma patient.  It may also greatly reduce the risk of metastasis by targeting free-floating cancer cells within the bloodstream.

What are the Risks of Cytoreductive Surgery?

Cytoreductive surgery carries with it similar risks to other forms of surgery. These risks are, to some extent, dictated by where the mesothelioma tumors in question reside. If the tumors are in the tunica vaginitis (a portion of the peritoneum “leftover” in the scrotal sac) the risks are relatively low. However, mesothelioma is much more common in the pleura within the chest cavity or the abdominal peritoneum. Any time you open the chest cavity or abdominal wall, you increase the risk for:

• Adverse events during surgery, including bleeding, hypothermia, thrombosis or other blood clotting events, hypothermia, etc.
• Infection
• Adverse reactions to anesthesia

However, cancer surgeries carry other risks as well. Because of the nature of the disease, mesothelioma can actually take advantage of surgical procedures to grow and spread to the operation site.  Essentially, if left untreated, the chances of the mesothelioma metastasizing or “taking up residence” in the region of the surgical procedure is very high. That’s because microscopic “cancer seeds” can latch on to the damaged tissue and survive the tumor removal procedure.  This risk can be greatly lessened through the use of perioperative chemotherapy or chemotherapy delivered immediately after surgery, called early postoperative chemotherapy.

Another risk is that the mesothelioma surgeon will miss a portion of the tumor. Because of the types of tissue in which mesothelioma tumors grow, they may be very difficult to identify by sight.  That’s why scientists have already begun working on ways to make cancerous tissue stand out from the healthy tissue that surrounds it, including using genetic alteration to add the luciferase gene from fireflies to mesothelioma cells to make tumors literally glow in the dark.

What are the Side Effects of Perioperative Chemotherapy?

The side effects of perioperative chemotherapy depend on which type of treatment is used. If the chemotherapy is localized, the side effects themselves may be the same as with systematic chemotherapy, only lessened in severity and duration. If the chemotherapy is delivered intravenously, the side-effect profile would be identical to that of traditional systematic chemotherapy.

Side effects can include:

• Decreased resistance to infection and disease
• Fatigue or weakness
• Hair loss
• Bleeding, bruising, or clotting events
• Appetite changes and accompanying weight loss/gain
• Fluid retention
• Digestive issues (vomiting, diarrhea, constipation)

Results of Cytoreductive Surgery Plus Perioperative Chemotherapy

Most mesothelioma experts agree that patients who undergo some form of cytoreductive surgery plus perioperative chemotherapy enjoy better results than other patients. Not only do they live longer, but they experience a better quality of life after their procedures. One Italian study discovered that survival rates in peritoneal mesothelioma patients quadrupled when patients underwent this combined therapy – with 47% of the study’s participants living past the five-year point. That’s quite a difference considering the average lifespan of a malignant peritoneal mesothelioma patient is just 12.5 months after diagnosis.

However, each individual case is different and results will vary greatly. Indeed, one recent study found the peritoneal mesothelioma patients who underwent complete removal of the outer layer of the peritoneum (called peritonectomy) fared better than patients who underwent cytoreductive surgery.