The development of more effective treatment options for patients with mesothelioma remains the most pressing issue facing physicians and researchers who work with the disease. Pleural mesothelioma is the most common form of the disease, so the majority of research programs that are conducted for the study of mesothelioma are devoted to the study of its pleural form. However, nearly 20% of all mesothelioma diagnoses are for peritoneal mesothelioma, where the malignancy attacks the peritoneum, which is the lining of the abdominal cavity. Because of this situation, even less is known about effective therapies for peritoneal mesothelioma than is known about general mesothelioma treatments. Large scale studies have been impossible to perform for patients with this variety of disease, so the major ways in which information has been shared among physicians has been through case reports made in journal articles. Even though these reports cannot replace the validity of results achieved with large scale studies, they are still able to share important information about the treatment of the malignancy and of the experience that individual physicians have had with individual mesothelioma patients.

One such article has recently been published in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. In it, the authors describe their experience treating a 49 year-old woman with pleural mesothelioma and peritoneal mesothelioma who presented with a painful ascites that was not responsive to any of the therapies attempted to treat it. Because of this, they treated the woman with a procedure known as laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC). The journal article describes the women’s presentation and their successful treatment of her malignant ascites.

Mesothelioma, Ascites and LHIPEC

Ascites is a condition where fluid has built-up within the abdominal cavity. It is common to a number of disorders and is associated with a number of painful symptoms, such as dyspnea, abdominal pain and nausea. When the ascites are caused by an underlying malignancy, such as peritoneal mesothelioma or colon cancer, other symptoms may include reduced mortality and malnutrition. Many of the traditional treatments for ascites, such as paracentesis or some form of shunting to move the fluid into a different area, are not often associated with successful symptom management. Because of this, alternative therapies are being researched on a number of fronts.

The authors note that one of these therapies, laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC), has achieved a 100% success rate in recently-published, retrospective studies involving the treatment of ascites. LHIPEC is a variant of traditionally-delivered heated intraperitoneal chemotherapy, but the chemo agents are delivered through laparoscopic entry techniques instead of a traditional laparotomy, which refers to a potentially large surgical incision that is made to facilitate open access to the abdomen. Because the use of laparoscopic techniques are associated with enhanced recovery time, LHIPEC is considered a potential option in cases where palliation is the primary concern.

Case Study

The authors describe the case of a 49 year-old woman who presented with “debilitating ascites” after pleural mesothelioma had spread to her abdomen. She initially received treatment for pleural mesothelioma in 2003 involving pleural decortication and adjuvant chemotherapy using pemetrexed and carboplatin. In 2006, CT scans showed a relapse of pleural mesothelioma, the spread of the disease to her peritoneum and the development of ascites. She was treated with further chemotherapy but integrated PET/CT showed gross spread of the disease and her mesothelioma symptoms continued to restrict her quality of life. Because of this, she underwent LHIPEC in January of 2007. Cisplatin and doxorubicin were the agents delivered.

After the operation, the patient was watched for 24 hours. During this initial period she developed a grade 4 hyponatremia, which is an abnormally low level of sodium in one’s blood, but this was treated upon discovery and soon corrected. She began taking food on the second post-op day, had the drains removed on the fourth day and was discharged on the seventh day after the surgery.

The procedure was a great success. The patient experienced noticeable improvements in symptom relief within a day of surgery, including a “complete remission of dyspnea and abdominal distension.” Her follow-up scans showed no signs the ascites were returning. She died six months after the procedure, but from a pulmonary embolism unrelated to her mesothelioma.

Conclusion

The authors feel that LHIPEC could be an important therapeutic option for the palliative treatment of malignant ascites. It seems to be well-tolerated and other recent studies have also shown its effectiveness for palliative purposes. The authors state that their article is only the second one to describe its use for the treatment of peritoneal mesothelioma and they call for more research into the use of LHIPEC. They also note that along with the symptom control they achieved—which the procedure was initially conducted for—their patient also demonstrated some therapeutic response to LHIPEC as post-op imaging scans showed a much lesser extent of ascites than before the procedure.

It is much too early to conclude that LHIPEC should be a regular option for the treatment of mesothelioma, but the results of this case report certainly point to the need for more research into the various forms of mesothelioma.

Labels: chemotherapy, mesothelioma, peritonealmesothelioma, treatments