Hyperthermic Intrathoracic Extracorporeal Chemotherapy for Pleural Malignancies
Daniel L Miller1, Jordan M Wetstone1, Rabih I Bechara2, Christopher S Parks2, Ioana R Bonta2, Patrica L Rich2
1Kennestone Regional Medical Center/WellStar Health System, Marietta, GA;2Southeastern Regional Medical Center/CTCA, Newnan, GA
OBJECTIVES: To evaluate the safety and efficacy of hyperthermic intrathoracic extracorporeal chemotherapy (HITEC) with cisplatin in patients who had undergone cytoreductive surgery pleurectomy/decortication (PD) for primary or secondary pleural malignancies (PM).
METHODS: After Health System and Cancer Committee approval, 25 patients who had unilateral chemoresistant pleural metastasis (15) or primary pleural malignancy (10) were registered prospectively. The patients' primary sites of malignancy were under control for a median of 36 months (range, 26 - 61) prior to developing PM. Median time of systemic chemotherapy for PM was 29 months (range, 28 - 76). Primary pleural malignancy (mesothelioma) patients were diagnosed within 3 months of HITEC. All 25 patients underwent a unilateral radical P/D and lymph node dissection, 60 minutes pleural lavage (1,500 - 1,700 cc/min) with 225 mg/m2 of cisplatin at 42°C. Cisplatin levels were drawn at time zero, 1 hour, 4 hours, and 24 hours after HITEC.
RESULTS: Median age was 57 years (range, 36 - 78); 20 patients (80%) were women. Metastatic tumor was breast in seven, thymus in four, colon in two, and renal cell and anal cancer in one each. Surgical approach was a thoracotomy in 23 patients (92%). Morbidity included prolonged air leak in six (24%), atrial fibrillation in three patients (12%), and acute respiratory distress syndrome in one (4%). Median hospital stay was 7 days (range, 4 - 14). Serum cisplatin levels peaked at 4 hours after lavage; no cisplatin levels were in the toxic range. Median dose of cisplatin was 392 mg (range, 250 - 450); no patient developed renal insufficiency. Median follow-up was 15 months (range, 1 - 24). Twenty-one patients (84%) had no signs of malignant disease at last follow-up; two patients (anal cancer - 6 months, mesothelioma - 10 months) developed local recurrence and two patients (renal cell cancer - 9 months, breast cancer - 10 months) developed metastatic disease, one contralateral pleural and the other liver, respectively. Two patients (8%) died from metastatic disease at 9 (anal cancer) and 12 months (mesothelioma) after HITEC. Twenty four patients (96%) experienced improved quality of life and respiratory function, as well as reduced pleuritic pain after PM cytoreduction and HITEC.
CONCLUSIONS: Surgical cytoreduction of primary or secondary pleural malignancies followed by HITEC with cisplatin was well tolerated. No patient developed cisplatin-related toxicities. Early results are promising. Longer follow-up is warranted to determine a survival and quality of life advantage as well as refinement of inclusion and exclusion criteria.
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