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Central Surgical Association

49th Annual Meeting

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Hyperthermic Intrathoracic Chemotherapy (HITHOC) During Resection of Malignant Pleural Mesothelioma Improves Patient Survival
*Irmina A. Elliott, Prasha Bhandari, *Natalie S. Lui, *Douglas Liou, *Joseph B. Shrager, *Mark F. Berry, *Leah M. Backhus
Cardiothoracic Surgery, Stanford University, Cupertino, California, United States


Objective
Malignant pleural mesothelioma is a rare disease with a poor prognosis. A multimodal treatment approach, including aggressive surgical resection, is associated with the best chance of remission and improved survival. Single-center studies have suggested that the use of hyperthermic intrathoracic chemotherapy (HITHOC) during surgical resection improves outcomes, but the impact of HITHOC on postoperative morbidity and patient survival has not been examined on a larger scale.

Methods
The National Cancer Database was queried for patients undergoing surgery for pleural mesothelioma from 2006-2017. Patients were excluded if staging or survival data was incomplete. Clinical outcomes were compared for patients receiving HITHOC versus those who did not using multivariable regression modeling. Additional propensity-score matching analysis was performed to adjust for patient selection biases. Perioperative outcomes and survival were analyzed for both matched and unmatched groups.

Results
The final cohort consisted of a total of 4,529 patients; of these, there were 396 patients who underwent HITHOC (Table 1). HITHOC therapy was associated with increased length of stay (12 vs. 5 days, p<0.001) and increased 30-day readmissions (9.6% vs. 4.4%, p<0.001), but equivalent 30-day mortality (2.8% vs. 4.4%, p=0.220), decreased 90-day mortality (6.6% vs. 13.2%), and improved 2-year survival (51.0% vs. 41.8%, p=0.010), which persisted following propensity matching. (Table 2). Kaplan-Meier Modeling demonstrated HITHOC therapy was associated with improved survival in the overall cohort (median 23.2 vs. 16.0 months, p<0.001, Figure 1), and in the propensity-score matched cohort (23.2 vs. 17.8 months, p=0.002, Figure 2). In multivariable analysis, HITHOC remained associated with improved overall survival (HR=0.67, p<0.001, Table 3). Other factors associated with improved overall survival were younger age, female sex, epithelioid histology, earlier stage disease, more recent year of diagnosis, and receipt of chemotherapy.

Conclusions
For the first time, we describe the impact of HITHOC on survival of patients with pleural mesothelioma using a large national database. Despite some increased short-term morbidity, HITHOC confers a significant 90-day, 2-year, and overall survival advantage for patients undergoing surgical resection of malignant pleural mesothelioma and should be considered as part of multimodality treatment.





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