Cytoreductive surgery followed by intraperitoneal hyperthermic perfusion is the standard treatment for resectable tumors at diagnosis. A preheated (42.5 degrees C) perfusate with 2 or 3 antineoplastic agents (cisplatin, mitomycin C, fluorouracil, doxorubicin, and/or paclitaxel) is infused mesothelioma continuously into the closed or semi-closed abdomen after surgery.
In a recent Phase II study[48] with cisplatin, mitomycin C and doxorubicin, the major morbidity rate reported was 12%: the most significant complications were anastomotic leaks (11%), abdominal bleeds (1.9%) and sepsis (1.9%). Operative mortality rate was 12%. In another study, after cytoreductive surgery and continuous hyperthermic peritoneal perfusion with cisplatin, fluorouracil, and paclitaxel, peritoneal progression-free and overall survival were mesothelioma treported to be 17 and 92 months, respectively. Deraco and colleagues reported 5-year overall survival, disease-free survival, and progression-free survival of 70%, 63%, and 51% respectively.[49]
Systemic chemotherapy has also been investigated. Pemetrexed in combination with cisplatin has shown survival improvement in patients with pleural mesothelioma. Data from uncontrolled studies suggest similar antineoplastic efficacy in patients with peritoneal mesothelioma,[50,51] and should be the standard of care for patients with unresectable malignant mesothelioma. The disease control rate reported is 71.2%: it includes partial responses or stable disease. No complete responses are reported for this chemotherapy.[52]
Other drug regimens used for unresectable disease are vinorelbine and gemcitabine, either alone or combined with platinum compounds.[51] The response rate of vinorelbine alone is 24%.[53] Irinotecan[54] and gefinitib[55] have not been shown to be effective when used alone.
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