Hyperthermic intrathoracic chemotherapy, a promising new treatment for pleural mesothelioma

By Michael Bartlett

Posted on January 18th, 2022

When it is part of the surgical treatment of pleural mesothelioma, hyperthermic intrathoracic chemotherapy, a relatively new therapy, yields promising results for patients. However, despite its effectiveness, hyperthermic intrathoracic chemotherapy is rarely administered to mesothelioma patients, who could truly benefit from it.

As part of a surgical strategy used to treat multiple pleural cancers, including mesothelioma, hyperthermic intrathoracic chemotherapy (HITHOC) entails delivering chemotherapy medication directly to the chest cavity during surgery. It is sometimes recommended to people who need a pleurectomy and decortication. Interestingly, HITHOC can be seen as the chest counterpart of HIPEC - heated intraperitoneal chemotherapy - which is used to treat patients with peritoneal mesothelioma. There are numerous benefits of HITHOC that are supported by reputable medical studies, including:

  • it can be used in aggressive multimodal cancer treatment
  • it destroys cancer locally in a way that is similar to radiation but with a lower risk of lung damage
  • it is associated with improved survival rates in some research studies

Nevertheless, HITHOC is deemed experimental by some medical specialists, although the procedure in and of itself does not imply a complex process. After the surgeon removes the visible cancer tumors via surgery, chemotherapy drugs are pumped into the chest cavity to soak all the organs to which the tumors have spread, destroying any malignant cells left behind. While studies found that pleural mesothelioma is more difficult to treat than peritoneal mesothelioma, which means that HITHOC has a slightly lower success rate than HIPEC, this form of chemotherapy still yields promising results for the former group of patients, as it can significantly contribute to their survival rate.

Who can undergo HITHOC?

Any pleural mesothelioma patient with a strong body to undergo aggressive treatment for this cancer can usually undergo HITHOC. Furthermore, some researchers suggest using this approach as a substitute for radiation therapy in cases where the latter is too dangerous for the person. Some patients require the removal of one lung and the affected tissue around it. Subsequently, the surgeon uses radiation to kill any cancer cells left behind in the chest cavity. Nonetheless, surgeons generally leave mesothelioma patients with both lungs intact.

During a pleurectomy and decortication, surgeons resect tumors around the lung and scrape cancer growth off the surface of the lung, which reduces the risk of complications and leads to a better quality of life. However, the issue is that it is dangerous to use radiation therapy if the lung remains in place because the tissue is very sensitive to radiation. This is where HITHOC comes into the picture, as it could provide surgeons with a safe way to destroy malignant cells in the chest when both lungs are present. According to Dr. Kristin Eckland, pleural mesothelioma patients who have pleural effusion and fall into one of the following three categories might be good candidates for HITHOC (Source: thoracics.org):

  • "0: Fully active, no restrictions on activities. A performance status of 0 means no restrictions in the sense that someone can do everything they were able to do prior to their diagnosis."
  • "1: Unable to do strenuous activities but can carry out light housework and sedentary activities. This status basically means you can't do heavy work but can do anything else."
  • "2: Able to walk and manage self-care but unable to work. Out of bed more than 50% of waking hours. In this category, people are usually unable to carry on any work activities, including light office work."

The benefits of HITHOC for pleural mesothelioma patients

In a study led by the famous Dr. David Sugarbaker, researchers examined the results of hundreds of pleural mesothelioma patients they had gathered during 8 years. Their goal was to compare the prognosis of the patients who received HITHOC to that of those who have not. Their analysis balanced both groups so that neither of them had any natural advantage outside of their treatment plan. According to the comparison, the group of mesothelioma patients who received HITHOC survived for 35.3 months, whereas the one that had lived only for 22.8 months, which is a significant difference.

It is important to note that HITHOC can be performed on pleural mesothelioma patients for multiple reasons, such as:

  • preventing kidney damage
  • removing the malignant tumors
  • heating the chest cavity
  • adding chemotherapy medication
  • finishing the surgery and recovery
  • offering adjuvant chemotherapy

Moreover, in a 2017 study, Italian researchers examined the results of 49 pleural mesothelioma patients who had received HITHOC between 2005 and 2014. In these cases, the surgeons tried to preserve lung and diaphragm function as much as possible. This way, patients would not experience irreversible breathing difficulty. The medical researchers reported that 79% of the patients were alive one year after the surgery, and 45% of them were alive two years after the procedure. Once again, the effectiveness of HITHOC can be observed, although not many studies have been conducted on the subject.

Including HITHOC in the standard treatment of pleural mesothelioma patients

Several renowned thoracic surgeons, including Dr. Marcelo Migliore and Dr. Stefan Hoffman, are currently spearheading HITHOC research programs and have authored the editorial for the December 2020 issue of the Annals of Translational Medicine. In the article, the authors discuss the absence of any mention or consideration of HITHOC for the treatment of pleural mesothelioma, despite multiple studies proving survival advantage for patients receiving it. The medical article was conducted by numerous departments of thoracic surgery worldwide, such as:

  • The Department of Cardio-Thoracic Surgery, University Hospital of Wales, UK
  • The Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
  • The Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
  • The Department of Thoracic Surgery, Catholic University of Barcelona, Barcelona, Spain

Despite the ASCO guidelines citing at least 3 papers reporting the experience of patients with HITHOC that have been included in the references list, this therapy is not considered an adjunct to surgery in the treatment of people with pleural mesothelioma, as researchers note. To prolong the survival of pleural mesothelioma patients, one of the primary aims in surgical treatment is to improve local tumor control within a multimodality treatment protocol after the procedure. One example in this respect is lung-sparing extended pleurectomy and decortication. Multimodality therapy should always be given to the patient after surgery, and HITHOC is just another type of local adjuvant treatment. The only difference is that it is carried out in the operating room immediately after surgery.

In conclusion, HITHOC shows abundant potential as adjuvant therapy in the treatment of pleural mesothelioma, and oncologists specializing in the treatment of this cancer should give it more consideration. Last but not least, more research should be conducted to evaluate how effective HITHOC really is, as the studies that have been conducted so far suggest that it is quite helpful to patients with this terrible disease and that it can considerably prolong their lives.

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