Phase I to II study of pleurectomy/decortication and intraoperative intracavitary hyperthermic cisplatin lavage for mesothelioma

Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma

INTRODUCTION

Pleurectomy/decortication (P/D) in the treatment of malignant pleural mesothelioma includes a number of procedures with different clinical indications and therapeutic intents. To unify the nomenclature, IMIG and IASLC recently defined P/D-related procedures according to surgical technique, including 'extended P/D', 'P/D' and 'partial pleurectomy'. The present systematic review aimed to assess the safety and efficacy of these techniques.

METHODS

A systematic review of relevant studies was performed by electronic search of five online databases from 1985 to 2012 by two independent reviewers according to predefined selection criteria.

RESULTS

Thirty-four studies involving 1916 patients who underwent pleurectomy were included for quantitative analysis. These included 12 studies on 'extended P/D', 8 studies on 'P/D' and 14 studies on 'partial pleurectomy'. Perioperative mortality ranged from 0% to 11% and perioperative morbidity ranged from 13% to 43%. Median overall survival ranged from 7.1 to 31.7 months and disease-free survival ranged from 6 to 16 months. One study reported on quality-of-life outcomes using a standardized questionnaire suggesting superior outcomes for 'extended P/D' compared to extrapleural pneumonectomy.

CONCLUSIONS

Results of the present systematic review suggested similar perioperative mortality outcomes between different P/D techniques but a trend towards higher morbidity and length of hospitalization for patients who underwent 'extended P/D'. However, overall and disease-free survival appeared to favour 'extended P/D' compared to less aggressive techniques. Future studies on P/D should adhere to recent definitions to enable accurate analysis of similar procedures. Direct comparisons of pleurectomy to extrapleural pneumonectomy remain challenging, and should be restricted to 'extended P/D' procedures only.

[Regional treatment of malignant pleural mesothelioma: results from the tumor centre Regensburg]

INTRODUCTION

Malignant pleural mesothelioma (MPM) is an aggressive, malignant tumor of the pleural surface and is strongly associated with asbestos exposure. Incidence of MPM will reach its peak over the coming years. Most patients present with advanced tumor stages and therefore surgical options are limited.

PATIENTS AND METHODS

Retrospective analysis of all patients with MPM reported to the tumor centre Regensburg between January 1998 and August 2011.

RESULTS

A total of 118 patients (85 % male) with cytologically or histologically confirmed MPM were reported. The mean age at diagnosis was 67 years (range 45-84 years) and 65 % of patients had a history of asbestos exposure. The incidence of MPM at the tumor centre Regensburg was 0.8/100,000 inhabitants with obvious regional differences depending on asbestos exposure. Staging was completed in 81 patients (67 %): stage I 9 %, stage II 22 %, stage III 23 % and stage IV 46 %. Of the patients 87 (74 %) underwent at least one surgical procedure: diagnostic thoracoscopy with biopsy (n = 37, 43 %), debulking surgery or talcum pleurodesis (n = 33, 38 %) and potentially curative resection (n = 17, 19 %). After a mean follow-up of 20 months the overall median survival was 14 months (1 year survival rate 62 %, 3 year survival rate 15 %). Patients had a significantly better median survival of 18 months after curative resection.

CONCLUSIONS

The distribution of MPM varies according to regional and industrial asbestos exposure. Screening and diagnostics should concentrate on locations with higher incidence of MPM to facilitate surgical therapy in a multimodal treatment regime.

Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies

OBJECTIVES

Malignant pleural effusion (MPE) means poor prognosis in the majority of cases. Intrapleural Hyperthermic perfusion chemotherapy (HIPEC) looks promising approach for these patients. We aimed to investigate whether cytoreductive surgery followed by HIPEC provides any survival benefit in cases with metastatic MPEs.

METHODS

Between January 2009 and December 2011, 19 patients with metastatic MPEs were treated with HIPEC following surgical interventions such as pleurectomy/decortication and/or lung resection (group 1). Comparison was done with historical control groups consisted of patients who received either talc pleurodesis or pleurectomy/decortication followed by systemic treatment for the management of metastatic MPEs between June 2007 and June 2008 (group 2 and 3). Statistical analyses including overall survival, disease free interval were done for the group comparisons.

RESULTS

Median survival in group 1, 2 and 3 were 15.4, 6, 8 months, respectively. One year survival was 54.7% in group 1 where it was 0.6% and 0.8% in group 2 and 3, respectively. There was no operative mortality. Morbidity was occurred in 1 patient in group 1 (5.3%).

CONCLUSIONS

HIPEC combined with cytoreductive surgery seems to be a promising treatment option for subjects with metastatic MPEs. Further studies are needed for the optimization of HIPEC method, drug of choice, and the best combination therapy for the multimodal treatment.

Hyperthermic intraoperative pleural cisplatin chemotherapy extends interval to recurrence and survival among low-risk patients with malignant pleural mesothelioma undergoing surgical macroscopic complete resection

OBJECTIVE

Local recurrence limits long-term survival in patients with malignant pleural mesothelioma. We investigated whether hyperthermic intraoperative cisplatin chemotherapy lavage affects the interval to recurrence and overall survival among patients with favorable prognostic factors.

METHODS

Using a preoperative risk assessment algorithm we had previously developed and validated, we retrospectively identified a cohort of patients treated with cytoreductive surgery from 2001 to 2009. The patients had epithelial histologic findings on biopsy and were characterized as having a low risk of early recurrence and death (ie, tumor volume ≤ 500 cm(3) and were either men with a hemoglobin level of ≥ 13 g/dL or were women). Those patients who had received hyperthermic intraoperative cisplatin chemotherapy were compared with a comparison group of those who had not. Fisher's exact test was used to determine the balance of prognostic factors. The Kaplan-Meier method and log-rank tests were used to estimate and compare the interval to recurrence and overall survival. Cox proportional hazards regression was used for multivariate analysis.

RESULTS

The cohort criteria identified 103 patients: 72 who received hyperthermic intraoperative cisplatin chemotherapy and 31 who did not. The groups were balanced for prognostic factors, except for the use of neoadjuvant chemotherapy (more common in the comparison group). The hyperthermic intraoperative cisplatin chemotherapy group exhibited a significantly longer interval to recurrence (27.1 vs 12.8 months) and overall survival (35.3 vs 22.8 months) than the comparison group. The improved interval to recurrence and overall survival for the hyperthermic intraoperative cisplatin chemotherapy group were particularly evident among the subgroups of patients who had not received hemithoracic radiotherapy and who had pathologic stage N1 or N2 lymph node metastases.

CONCLUSIONS

A favorable outcome and minimal incremental morbidity support the incorporation of hyperthermic intraoperative cisplatin chemotherapy into multimodality treatment strategies for patients with low-risk epithelial malignant pleural mesothelioma.

Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies

BACKGROUND

Assessing the pharmacokinetics of intrapleurally administered cisplatin during hyperthermic intrathoracic chemotherapy perfusion (HITHOC) following pleurectomy/decortication in patients with malignant pleural mesothelioma or advanced thymoma with pleural spread.

METHODS

Pharmacokinetic analysis (ICP-MS) of intrapleural cisplatin with a dosage of 100 mg/m(2) (n = 5) or 150 mg/m(2) (n = 5) at 42°C perfusate temperature. Simultaneous pleural perfusion fluid and serum samples were collected at the beginning and every 15 min. Serum samples were collected at the end of the operation, 6, 12, and 24 hr postoperative.

RESULTS

Mean cisplatin levels in the perfusate slightly decreased during the HITHOC. The mean area under the curve ratios (AUC perfusate :AUC serum ) of cisplatin were nearly similar. The mean AUCs of cisplatin in the perfusate were approximately 58 and 55 times greater than detected in the serum. The mean peak of cisplatin in the serum was reached after 1 hr of HITHOC. The AUC of cisplatin in the serum did not significantly differ (P = 0.18) between both groups up to 24 hr after perfusion.

CONCLUSIONS

HITHOC with cisplatin provides a pharmacological advantage of high local intrapleural cisplatin concentrations. Elevation of the cisplatin dosage to 150 mg/m(2) did not lead to a significant increase of the systemic cisplatin concentration.

Changes in lung function after surgery for mesothelioma

Background: The effect of pleurectomy/decortication or extrapleural pleuropneumonectomy on pulmonary function has not yet been evaluated. The aim of this study was to determine the parameters of pulmonary function before and after pleurectomy/decortication or extrapleural pleuropneumonectomy.

Methods: We conducted a review of 48 patients with unilateral malignant pleural mesothelioma who underwent pleurectomy/decortication or extrapleural pleuropneumonectomy. Data including medical history, histology, survival, and pre- and postoperative pulmonary function were extracted from the medical database of the University Medical Center Freiburg, or sought by telephone interview with the general practitioner or patients.

Results: 25 patients underwent extrapleural pleuropneumonectomy and 23 had pleurectomy/decortication. Pulmonary function was not significantly reduced in the pleurectomy/decortication group postoperatively. In the extrapleural pleuropneumonectomy group, the median preoperative total lung capacity of 4.8 L (77.7%) differed significantly from the postoperative total lung capacity of 3.5 L (55.3%; p < 0.0006). The median vital capacity was significantly reduced from 2.8 L (77.7%) preoperatively to 1.8 L (47.6%) postoperatively ( p < 0.0002). Other parameters were also highly significantly reduced after extrapleural pleuropneumonectomy.

Conclusions: Pleurectomy/decortication preserved good pulmonary function, whereas extrapleural pleuropneumonectomy significantly reduced pulmonary function, which may lead to dyspnea and influence the quality of life of these patients.

Drug-induced atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common arrhythmia and an important cause of hospitalization, morbidity, and mortality. A myriad of drugs can induce AF. However, drug-induced AF (DIAF) receives little attention. Thus, this review is an attempt to attract the attention on this adverse effect.

AREAS COVERED

Published reports of drug-induced AF (DIAF) are reviewed in this paper, from January 1974 to December 2011, using the PubMed/Medline database and lateral references.

EXPERT OPINION

In most cases, DIAF is paroxysmal and terminates spontaneously, but sometimes AF persists and it is necessary to perform a cardioversion to restore sinus rhythm and avoid progression to persistent AF. Because of the short duration of DIAF, in addition to physicians/patients not being knowledgeable about this side effect, the real incidence and clinical consequences of DIAF are presently unknown. DIAF is an increasing problem, as some widely prescribed drugs can present this adverse effect. The risk is expected to increase in the elderly and in patients with comorbidities. It is important that physicians understand the significance of DIAF, to increase the collaboration between cardiac and non-cardiac professionals, and to educate patients to make them aware of this adverse side effect.

A multifunctional mesothelin antibody-tagged microparticle targets human mesotheliomas

Pleural and peritoneal mesotheliomas (MMs) are chemoresistant tumors with no effective therapeutic strategies. The authors first injected multifunctional, acid-prepared mesoporous spheres (APMS), microparticles functionalized with tetraethylene glycol oligomers, intraperitoneally into rodents. Biodistribution of APMS was observed in major organs, peritoneal lavage fluid (PLF), and urine of normal mice and rats. After verification of increased mesothelin in human mesotheliomas injected into severe combined immunodeficient (SCID) mice, APMS were then functionalized with an antibody to mesothelin (APMS-MB) or bovine serum albumin (BSA), a nonspecific protein control, and tumor targeting was evaluated by inductively coupled plasma mass spectrometry and multifluorescence confocal microscopy. Some APMS were initially cleared via the urine over a 24 hr period, and small amounts were observed in liver, spleen, and kidneys at 24 hr and 6 days. Targeting with APMS-MB increased APMS uptake in mesenteric tumors at 6 days. Approximately 10% to 12% of the initially injected amount was observed in both spheroid and mesenteric MM at this time point. The data suggest that localized delivery of APMS-MB into the peritoneal cavity after encapsulation of drugs, DNA, or macromolecules is a novel therapeutic approach for MM and other tumors (ovarian and pancreatic) that overexpress mesothelin.

Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma

OBJECTIVES

There is a body of opinion that advocates extrapleural pneumonectomy (EPP) as the only radical treatment option for locally advanced (T3/T4) malignant pleural mesothelioma (MPM). We tested the hypothesis that lung-sparing total pleurectomy (LSTP) can be as effective as EPP in locally advanced MPM with reduced risk.

METHODS

We analysed prospective data on 165 patients (128 with epithelioid and 37 with biphasic MPM) with pT3 (n = 108) and pT4 (n = 57) tumours. Ninety-eight (59.4%) of the patients underwent EPP and 67 (40.6%) LSTP. We compared intergroup differences in: length of stay (LOS), post-operative complications, survival, pattern of disease progression and disease-free interval (DFI).

RESULTS

There were significantly more complications after EPP: 67 (68%) vs. 29 (43%) in LSTP, P = 0.002. Thirty-day mortality was 7% for EPP and 3% for LSTP (P = 0.31). LOS was similar (mean 19 days for EPP, 15 days for LSTP, P = 0.19). We noted only minor differences in the initial site of disease progression. In 33 (41%) of EPP patients, disease progressed locally compared with 22 (44%) after LSTP. Seventeen patients post-EPP (21%) had distal progression compared with only three (6%) post-LSTP and synchronous distal and local recurrence was similar: 15 (19%) post-EPP vs. 12% for LSTP (P = 0.11). There was no significant intergroup difference in median survival: EPP 14.7 months (SE 1.3, 95% CI 12.2-17.2) vs. LSTP 13.4 months (SE 1.9, 95% CI 9.7-17.1), P = 0.91, nor in DFI: EPP 10.7 months (SE 0.8, 95% CI 9-12) vs. LSTP 16 months (SE 1, 95% CI 9-22). In chemonaive patients (n = 124), adjuvant chemotherapy was received by significantly more patients after LSTP (32/53 LSTP vs. 26/71 EPP patients, P = 0.011). Estimated 1-5 years survival for EPP was 58, 30, 11, 9 and 6% and for LSTP 52, 28, 20, 13 and 4%.

CONCLUSIONS

In disagreement with standard opinion, we advocate LSTP as the procedure of choice in locally advanced MPM: it offers at least equally as good oncological results as EPP in this group of patients with reduced early complications. Despite a tendency for increased local recurrence in the LSTP group, overall survival is not compromised.

Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the international association for the study of lung cancer international staging committee and the international mesothelioma interest group

INTRODUCTION

Extrapleural pneumonectomy has been well defined; however, surgeons vary regarding the surgical extent and goals of "pleurectomy/decortication" (P/D). We explored mesothelioma surgeons' concepts of P/D with the aim of unifying surgical nomenclature.

METHODS

A web-based survey was administered to surgeons who operated on malignant pleural mesothelioma (MPM) for diagnosis, staging, palliation, or cytoreduction. One hundred thirty surgeons from 59 medical centers were included. Surgeons who did not perform surgery for MPM within the last year were excluded.

RESULTS

There were 62 (48%) respondents from 39 medical centers in 14 countries. The mean number of patients with MPM seen annually at each medical center was 46, and the mean annual number of cytoreductive procedures performed per surgeon was 8. Most (88%) agreed that the goal of cytoreductive surgery should be macroscopic complete resection of tumor. P/D was defined as resection of parietal and visceral pleura with the aim of achieving macroscopic complete resection by 72% of respondents. If the diaphragm or pericardium required resection, 64% preferred the term "radical P/D," whereas "P/D" (40%) or "total pleurectomy" (39%) was preferred if these structures were not removed. Most surgeons believed that extrapleural pneumonectomy (90%) or "radical P/D" (68%) could provide adequate cytoreduction, whereas only 23% thought that P/D could.

CONCLUSIONS

There was significant variation regarding surgical nomenclature for procedures for MPM. The International Staging Committee of the International Association for the Study of Lung Cancer and the International Mesothelioma Interest Group recommend that P/D should aim to remove all macroscopic tumor involving the parietal and visceral pleura and should be termed "extended" P/D when the diaphragm or pericardium is resected.

The evolution of multimodality therapy for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare neoplasm of the pleural surfaces that has been associated with asbestos exposure. MPM generally spreads locally along the ipsilateral pleura, especially at presentation, with distant metastatic disease typically seen only in the later stages of the disease course. As such, surgical resection and other local therapies have long been pursued as a primary form of treatment. Surgical options include debulking of the pleura by pleurectomy/decortication (P/D) or a more aggressive extrapleural pneumonectomy (EPP) which also involves removal of the lung, diaphragm, and involved pericardium. Even after major resection, MPM almost always recurs locally and has a poor prognosis. As such, many groups have pursued multimodality therapy, treating resectable patients with EPP, along with hemithoracic radiation to decrease the risk of local recurrence and chemotherapy to decrease the risk of distant metastatic disease. However, EPP is associated with significant morbidity and mortality, and many patients are not candidates for EPP due to underlying comorbid medical conditions. Additionally, many patients are unable to tolerate complete courses of adjuvant therapy after EPP. A large, multicenter retrospective analysis comparing EPP to P/D demonstrated better outcomes among those who underwent P/D. One challenge associated with P/D has been the delivery or radiation to the removed pleura with an intact lung. Yet, advances in radiation technique have allowed the exploration of high-dose radiation therapy after P/D. The ideal timing of chemotherapy relative to surgery and the role of intracavitary chemotherapy continue to be controversial issues. Clearly, MPM requires a multidisciplinary approach and, due to the myriad of open questions, much effort continues to focus on identifying the optimal combination of surgery, chemotherapy, and radiation.

Surgical treatment of malignant pleural mesothelioma

Malignant Pleural Mesothelioma (MPM) remains a rare and lethal disease that is directly related to asbestos exposure in the vast majority of cases. While the total number of cases remains low compared to other malignancies, the worldwide incidence is expected to increase over the next twenty years. Currently, survival rates remain dismal and there is no standard therapy or consensus regarding treatment. However, over the last fifteen years there have been substantial improvements in the diagnosis and treatment of MPM, including easier and more accurate diagnostic techniques, improved methods of staging, more effective systemic therapy, a remarkable decrease in operative mortality, marked improvements in local control with adjuvant therapy, and perhaps most important, an emphasis on multidisciplinary care and multimodality clinical trials. Despite these advances, optimal therapy for these patients remains highly controversial and the role of surgery is actively debated. Most controversy centers on whether surgery increases survival and whether a survival benefit is best achieved with extrapleural pneumonectomy or pleurectomy/decortication within a multimodal regimen. To date, trimodality therapy that includes surgery, chemotherapy, and radiation offers the best survival advantage. It is generally accepted that the main goals of surgery, within the framework of a multimodality approach, is not only complete resection if possible, but more realistically, the resection of all macroscopic disease as an adjunct to the delivery of chemotherapy and radiation. The surgical options available to obtain this goal include extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). There are no randomized trials directly comparing EPP and P/D and the level of evidence supporting either technique remains low. Ultimately, the choice of operation depends on multiple factors including: disease stage, the patient's cardiopulmonary reserve, surgeon experience and philosophy, and the extent of planned adjuvant therapy. Yet, despite the inherent biases in most studies, the data thus far illustrates significant survival advantages with both P/D and EPP and surgeons should consider these approaches in select patients.

Genes associated with prognosis after surgery for malignant pleural mesothelioma promote tumor cell survival in vitro

Background

Mesothelioma is an aggressive neoplasm with few effective treatments, one being cytoreductive surgery. We previously described a test, based on differential expression levels of four genes, to predict clinical outcome in prospectively consented mesothelioma patients after surgery. In this study, we determined whether any of these four genes could be linked to a cancer relevant phenotype.

Methods

We conducted a high-throughput RNA inhibition screen to knockdown gene expression levels of the four genes comprising the test (ARHGDIA, COBLL1, PKM2, TM4SF1) in both a human lung-derived normal and a tumor cell line using three different small inhibitory RNA molecules per gene. Successful knockdown was confirmed using quantitative RT-PCR. Detection of statistically significant changes in apoptosis and mitosis was performed using immunological assays and quantified using video-assisted microscopy at a single time-point. Changes in nuclear shape, size, and numbers were used to provide additional support of initial findings. Each experiment was conducted in triplicate. Specificity was assured by requiring that at least 2 different siRNAs produced the observed change in each cell line/time-point/gene/assay combination.

Results

Knockdown of ARHGDIA, COBLL1, and TM4SF1 resulted in 2- to 4-fold increased levels of apoptosis in normal cells (ARHGDIA only) and tumor cells (all three genes). No statistically significant changes were observed in apoptosis after knockdown of PKM2 or for mitosis after knockdown of any gene.

Conclusions

We provide evidence that ARHGDIA, COBLL1, and TM4SF1 are negative regulators of apoptosis in cultured tumor cells. These genes, and their related intracellular signaling pathways, may represent potential therapeutic targets in mesothelioma.

Optimized intrapleural cisplatin chemotherapy with a fibrin carrier after extrapleural pneumonectomy: a preclinical study

OBJECTIVE

Our objective was to evaluate whether platinum concentrations in chest wall tissue and in serum are optimized by intracavitary application of cisplatin loaded to a fibrin carrier compared with cisplatin solution in a randomized setting of a pig model.

METHODS

After left-sided pneumonectomy including parietal pleurectomy, pigs were randomly assigned to receive either 90 mg/m(2) cisplatin intracavitary solution (n = 6) or to receive 5 mg cisplatin-fibrin (n = 5) applied on a predefined area of the chest wall. Platinum concentration in serum as well as in chest wall tissue was determined at several early time points until day 5 after treatment. Platinum levels were measured by inductively coupled plasma sector field mass spectrometric detection with a matrix-matched calibration procedure.

RESULTS

The dose- and surface-corrected (geometric) mean concentration of cisplatin in chest wall tissue 2 hours but also at day 5 after the application was doubled in animals treated with cisplatin-fibrin compared with the animals treated with cisplatin-solution. In serum, the dose- and surface-corrected exposure toward cisplatin (area under the curve(0-5d)) was significantly lower with cisplatin-fibrin than with cisplatin-solution (P < .0005). This is also reflected by significantly reduced serum creatinine and urea values in the cisplatin-fibrin group (P < .0001). Animals treated with cisplatin-fibrin additionally had a significantly better postoperative course as assessed by a well-being score (P < .001).

CONCLUSIONS

After cisplatin-fibrin treatment, cisplatin tissue concentration was increased whereas systemic cisplatin concentrations were significantly reduced in comparison with cisplatin-solution treatment. This finding offers a clear advantage inasmuch as rate and severity of systemic adverse events can be reduced while local cytotoxic concentrations are at least maintained.

Surgical therapy of mesothelioma

The treatment of malignant pleural mesothelioma is controversial, particularly regarding the role of surgery. Though well accepted as a diagnostic modality, surgery is also frequently used to establish stage, provide palliation, and perhaps most controversially, to offer cytoreduction with the putative goal of delaying tumor progression and prolonging survival. Pleurectomy/decortication (PD) can achieve macroscopic complete resection; however, the ability to deliver effective postoperative radiation treatment is limited because of the risk of lung toxicity. Accordingly, it has been associated with higher rates of local recurrence compared to extrapleural pneumonectomy (EPP). Extrapleural pneumonectomy generally offers a more complete cytoreduction compared to PD but at the cost of increased morbidity and mortality. Adjuvant hemithoracic radiation is feasible following EPP and in most series local recurrence rates are lower after EPP than PD. There are no convincing data, however, to show that one procedure is superior to the other in terms of survival. Furthermore, no randomized data currently exist that demonstrate a survival benefit to any form of surgical cytoreduction over systemic treatment and supportive care. If cytoreductive surgery does have a beneficial effect on long-term survival, it will most likely be realized in patients with epithelioid tumors without nodal metastases.

Increased efficacy of doxorubicin delivered in multifunctional microparticles for mesothelioma therapy

New and effective treatment strategies are desperately needed for malignant mesothelioma (MM), an aggressive cancer with a poor prognosis. We have shown previously that acid-prepared mesoporous microspheres (APMS) are nontoxic after intrapleural or intraperitoneal (IP) administration to rodents. The purpose here was to evaluate the utility of APMS in delivering chemotherapeutic drugs to human MM cells in vitro and in two mouse xenograft models of MM. Uptake and release of doxorubicin (DOX) alone or loaded in APMS (APMS-DOX) were evaluated in MM cells. MM cell death and gene expression linked to DNA damage/repair were also measured in vitro. In two severe combined immunodeficient mouse xenograft models, mice received saline, APMS, DOX or APMS-DOX injected directly into subcutaneous (SC) MM tumors or injected IP after development of human MMs peritoneally. Other mice received DOX intravenously (IV) via tail vein injections. In comparison to DOX alone, APMS-DOX enhanced intracellular uptake of DOX, MM death and expression of GADD34 and TP73. In the SC MM model, 3× weekly SC injections of APMS-DOX or DOX alone significantly inhibited tumor volumes, and systemic DOX administration was lethal. In mice developing IP MMs, significant (p < 0.05) inhibition of mesenteric tumor numbers, weight and volume was achieved using IP administration of APMS-DOX at one-third the DOX concentration required after IP injections of DOX alone. These results suggest APMS are efficacious for the localized delivery of lower effective DOX concentrations in MM and represent a novel means of treating intracavitary tumors.

[Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion]

Recently cytoreductive surgery of primary and secondary pleural tumors has been combined with hyperthermic intrathoracic chemotherapy perfusion (HITHOC) for better local tumor control. In comparison to simple instillation of chemotherapeutic agents into the pleural cavity, the combination of surgical resection of pleural tumors and simultaneous HITHOC seems to be a more effective treatment. Intra-operative perfusion allows an improved distribution of the drug in the pleural space and a higher local concentration of the chemotherapeutic agents in contrast to systemic chemotherapy. Additional advantages of HITHOC are a better response to chemotherapeutic agents and synergistic antineoplastic effects. A prerequisite for safe application of HITHOC is compliance with safety regulations. Due to the reduction in morbidity and mortality this new concept is a valuable alternative for selected patients who do not undergo radical resection (e.g. extrapleural pneumonectomy). HITHOC is an additional therapeutic option in the multimodal treatment of patients with primary or secondary tumors of the pleura.

Intracavitary cisplatin therapy for pediatric malignancies

BACKGROUND

Local control is essential for the successful treatment of pediatric solid tumors. Complete excision is often not possible and local control therapies are limited. Intracavitary cisplatin (IC-CDDP) may be utilized to supplement local control. The aim of the study was to determine the toxicity and efficacy of locally instilled intracavitary cisplatin in patients with recurrent tumors in closed body cavities.

PROCEDURE

From 2001 to 2009, 12 patients (1-20 years) with recurrent or unresectable malignant tumors were treated with IC-CDDP. Nine had pulmonary lesions. Three patients had abdominal tumors. CDDP (200 mg/m(2)) was instilled by chest tube or Tenckhoff catheter. Patients were shifted every 15-30 min to allow distribution. After 4 hr, residual was drained by gravity. In 10/13 courses, sodium thiosulfate (STS) was administered to prevent nephrotoxicity. Three other patients received amifostine.

RESULTS

Malignant pleural effusions resolved in 5/7 patients. This response was temporary in three patients. No patients had ascites prior to treatment. Three patients are alive and disease-free, 18 months, 4 years, and 6 years from treatment. They also had surgery and chemotherapy. Transient renal toxicity was noted in most patients. One patient, treated with amifostine, had persistent renal dysfunction.

CONCLUSIONS

IC-CDDP was effective in treating malignant pleural effusions and may be a palliative option for refractory disease. Long-term survival was achieved in two patients, treated at first diagnosis. The benefit of IC-CDDP in these patients is difficult to assess. Renal dysfunction is usually mild, and typically resolves, but warrants preventive measures with IC-CDDP therapy.

Cold-plasma coagulation in the treatment of malignant pleural mesothelioma: results of a combined approach

Malignant pleural mesothelioma is on a continuous rise throughout the Western countries. It is associated with asbestos fibre exposition in the past. Surgical approaches include extrapleural pneumonectomy and pleurectomy/decortication (P/D). We investigated the feasability of the implementation of cold-plasma coagulation (CPC) on the pleura, pericardium and diaphragm into an established therapeutic algorithm consisting of P/D and hyperthermic intrathoracal chemoperfusion (HITHOC) therapy. The underlying rationale was the prevention of cardiotoxic effects during HITHOC as well as accidental translocation of malignant cells to the abdomen. CPC was done as part of a multimodal therapy in stage III mesothelioma patients. Histologic examinations of pleural excisates after CPC were done. The patients were followed up in three-month intervals. Neither parenchymal fistulas, nor cardiotoxic effects were observed. The histologic examination of the pleural excisates showed complete predictable necrosis. Moreover, until now (median time after operation 1 year) no relapse of the disease was observed. CPC proved to be a safe technique when used on the pleura, pericardium and diaphragm. We consider our trial as a pilot-study. To evaluate potential survival benefits using this technique larger trials are mandatory.

Making the case for molecular staging of malignant pleural mesothelioma

Malignant pleural mesothelioma is an aggressive malignancy for which surgical treatment is an option for a subset of patients. A gene ratio test based on the relative expression levels of four genes has been validated in clinical trials to predict which patients will benefit from surgical therapy. A description of the test properties and the independent predictors for outcome are provided.

Extrapleural pneumonectomy followed by intracavitary intraoperative hyperthermic cisplatin with pharmacologic cytoprotection for treatment of malignant pleural mesothelioma: a phase II prospective study

OBJECTIVE

We sought to prospectively determine the feasibility and safety of hyperthermic intraoperative intracavitary cisplatin perfusion immediately after extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.

METHODS

Patients with malignant pleural mesothelioma who were surgical candidates underwent extrapleural pneumonectomy followed by hyperthermic intraoperative intracavitary cisplatin perfusion, consisting of a 1-hour lavage of the chest and abdomen with cisplatin (42 degrees C) at 225 mg/m(2). Pharmacologic cytoprotection consisted of intravenous sodium thiosulfate with or without amifostine. Morbidity and mortality were recorded prospectively.

RESULTS

Ninety-six (79%) of 121 enrolled patients underwent extrapleural pneumonectomy, of whom 92 (76%) received hyperthermic intraoperative intracavitary cisplatin perfusion after extrapleural pneumonectomy. Fifty-three (58%) patients had epithelial tumors, and 39 (42%) had nonepithelial histology. Hospital mortality was 4.3%. Morbidity (grade 3 or 4, 49%) included atrial fibrillation in 22 (23.9%) patients, venous thrombosis in 12 (13%) patients, and laryngeal nerve dysfunction in 10 (11%) patients. Nine patients had renal toxicity, which was attributable to cisplatin in 8 of them. Among the 27 patients who also received amifostine (910 mg/m(2)), 1 patient had grade 3 renal toxicity attributable to cisplatin. Recurrence of malignant pleural mesothelioma was documented in 47 (51%) patients, with ipsilateral recurrence in 17.4% of patients. The median survival of the 121 enrolled patients was 12.8 months.

CONCLUSIONS

Hyperthermic intraoperative intracavitary cisplatin perfusion following extrapleural pneumonectomy can be performed with acceptable morbidity and mortality. The use of amifostine in addition to sodium thiosulfate might reduce cisplatin-associated renal toxicity. Hyperthermic intraoperative intracavitary cisplatin perfusion following extrapleural pneumonectomy might enhance local control in the chest.

Mesothelioma cells escape heat stress by upregulating Hsp40/Hsp70 expression via mitogen-activated protein kinases

Therapy with hyperthermal chemotherapy in pleural diffuse malignant mesothelioma had limited benefits for patients. Here we investigated the effect of heat stress on heat shock proteins (HSP), which rescue tumour cells from apoptosis. In human mesothelioma and mesothelial cells heat stress (39-42 degrees C) induced the phosphorylation of two mitogen activated kinases (MAPK) Erk1/2 and p38, and increased Hsp40, and Hsp70 expression. Mesothelioma cells expressed more Hsp40 and were less sensitive to heat stress compared to mesothelial cells. Inhibition of Erk1/2 MAPK by PD98059 or by Erk1 siRNA down-regulated heat stress-induced Hsp40 and Hsp70 expression and reduced mesothelioma cell survival. Inhibition of p38MAPK by SB203580 or siRNA reduced Hsp40, but not Hsp70, expression and also increased mesothelioma cell death. Thus hyperthermia combined with suppression of p38 MAPK or Hsp40 may represent a novel approach to improve mesothelioma therapy.

Four-gene expression ratio test for survival in patients undergoing surgery for mesothelioma

BACKGROUND

Malignant pleural mesothelioma has few effective treatments, one being cytoreductive surgery. We previously developed a gene ratio test to predict outcome of malignant pleural mesothelioma patients undergoing surgery. In this study, we investigated the predictive value and technical assay performance of this test in patients with malignant pleural mesothelioma.

METHODS

Clinical data were obtained prospectively from 120 consecutive patients with malignant pleural mesothelioma who were scheduled for debulking surgery at one institution. Specimens were obtained at surgery or by pleural biopsy examination. Expression data for four genes were collected from tumor specimens, and three ratios of gene expression (TM4SF1/PKM2, TM4SF1/ARHGDIA, and COBLL1/ARHGDIA) were determined by quantitative reverse transcriptase-polymerase chain reaction. Patients were assigned to good or poor outcome groups by the gene ratio test. Survival was estimated by the Kaplan-Meier method and the log-rank test in univariate analyses. A multivariable Cox proportional hazards model was used to control for prognostic factors. Technical robustness was determined by using up to 30 specimens per patient, two biopsy techniques, and two performance sites. All statistical tests were two-sided.

RESULTS

The test predicted overall survival (P < .001) and cancer-specific survival (P = .007) in univariate analysis and overall survival in multivariable analysis (hazard ratio for death = 2.09, 95% confidence interval [CI] = 1.27 to 3.45, P = .004). The test was reproducible within patients and repeatable between two determinations for specimens with widely varying tumor cell contents. Repeatability between two determinations was 88.5% (95% CI = 84.0% to 92.2%) or, when technically unacceptable test values were excluded, 91.9% (95% CI = 87.4% to 95.1%). Reproducibility between two determinations was 96.1% (95% CI = 86.5% to 99.5%). Combining the gene ratio test and other prognostic factors allowed prospective discrimination between patients at high risk (median survival = 6.9 months, 95% CI = 2.6 to 8.9 months; 3-year survival = 0%) and low risk (median survival = 31.9 months, 95% CI = 21.9 to 41.7 months; 3-year survival = 42%).

CONCLUSION

The gene ratio test for survival of patients with malignant pleural mesothelioma has robust predictive value and technical assay performance.

Neoadjuvant and intrapleural therapies for malignant pleural mesothelioma

Historically, malignant pleural mesothelioma patients with potentially resectable disease have been treated with surgery and radiation alone. With improvements in systemic and intrapleural treatment options, a movement toward multi-modality therapy has become more common. Systemic treatment options largely consist of neoadjuvant chemotherapy with platinum doublets and most recently novel targeted agents, such as dasatinib. Intrapleural strategies have included injecting chemotherapy, chemotherapy with hyper thermic per fusion, gene therapy, and immunotherapy. The following review discusses the latest results in neoadjuvant and intrapleural therapies in malignant pleural mesothelioma.

A phase I study of extrapleural pneumonectomy and intracavitary intraoperative hyperthermic cisplatin with amifostine cytoprotection for malignant pleural mesothelioma

OBJECTIVE

This study was undertaken to determine maximum tolerated dose and toxicity of intraoperative intracavitary hyperthermic cisplatin perfusion with amifostine after extrapleural pneumonectomy for malignant pleural mesothelioma.

METHODS

Patients with mesothelioma were prospectively enrolled. Those with resectable disease received amifostine and 1-hour hyperthermic cisplatin perfusion of ipsilateral hemithorax and abdomen. Morbidity, recurrence, and survival were recorded.

RESULTS

Forty-two patients were enrolled; 29 underwent resection (operative mortality 7%, 2/29). Median age was 57 years. Eighteen were in pathologic stage I or II; 11 were in stage III. Median hospitalization was 15 days. Common complications were atrial fibrillation (66%, 19 patients), deep venous thrombosis (31%, 9 patients), and grade 3+ renal toxicity (31%, 9 patients). Feasibility was determined. Renal toxicity was unrelated to cisplatin dose, with no maximum tolerated dose determined. Overall median survival was 17 months (resected 20 months, unresected 10 months). Median survivals were 26 months for patients receiving higher cisplatin doses and 16 months for those receiving lower doses (P = .35). Survival was significantly longer with negative extrapleural nodes (31 vs 14 months, P = .0115) and early stage (all resected 35 months for stage I-II vs 14 months for stage III, P = .0022, epithelial 39 months for stage I-II vs 15 months for stage III, P = .0072).

CONCLUSION

Early stage and negative extrapleural lymph nodes were associated with prolonged survival. Single-dose amifostine did not protect adequately against cisplatin-induced renal toxicity. Additional cytoprotective strategies are needed to allow determination of cisplatin maximum tolerated dose.

Recent advances in the treatment of malignant pleural mesothelioma

Malignant pleural mesothelioma clinically manifests after decades of initial exposure to etiologic agents, such as asbestos, and presents with nonspecific symptoms such as dyspnea, pain, or weight loss. In patients with limited, resectable disease, surgical therapy with extrapleural pneumonectomy or pleurectomy is recommended, although, it is unclear which approach is superior. Radiation has a limited role and is used primarily for palliation. The palliative efficacy of traditional chemotherapeutic agents and combination regimens is modest at best. The combination of cisplatin and pemetrexed, a novel multitargeted antifolate agent, is the approved "standard of care" for patients with unresectable malignant pleural mesothelioma. A number of molecularly targeted agents are currently under evaluation for mesothelioma such as the Histone deacetylase (HDAC) inhibitors that have demonstrated promising anticancer activity. Vorinostat, a small molecule inhibitor of HDAC, which targets select members of class I and II HDACs, has shown early evidence of activity and is currently being evaluated in a randomized study for patients who progress with standard therapy for advanced mesothelioma. It is hoped that the HDAC inhibitors and other novel targeted agents will pave the way for improved outcomes for patients with this disease.

Malignant mesothelioma 2008

PURPOSE OF REVIEW

Mesothelioma is an aggressive malignancy of the pleura with poor survival. There will be approximately 3000 cases of mesothelioma in the United States annually. Multimodality treatment including neoadjuvant chemotherapy in selected individuals followed by extrapleural pneumonectomy and radiation has been studied in recent trials for its effects on disease free and overall survival This review provides a general overview of malignant mesothelioma with a summary of the most significant articles from within the past year as well as from the past.

RECENT FINDINGS

Areas of recent interest include the evaluation of osteopontin and mesothelin as new tumor markers for mesothelioma. New phase III trials have been performed to evaluate the use of combined chemotherapy regimens.

SUMMARY

Malignant mesothelioma is a very difficult malignancy to treat. Patients with the disease usually have an occupational asbestos exposure, and in some, viral exposure with SV40. There have been many historical treatments including combinations of local control with surgery and radiation as well as attempts to prevent systemic failure with chemotherapy. Novel therapies including intrapleural chemotherapy, photodynamic therapy and hyperthermic perfusion have also been used with some success. Finally there are several attempts at immunomodulating and targeted treatments, which are in phase I/II trials.

A phase II trial of tetrathiomolybdate after surgery for malignant mesothelioma: final results

BACKGROUND

Tetrathiomolybdate (TM) is an oral copper-depleting agent that has been shown to inhibit angiogenesis, and angiogenesis is a predictor of poor prognosis in malignant pleural mesothelioma. We hypothesized that cytoreduction of malignant pleural mesothelioma followed by TM will delay time to progression.

METHODS

Between November 2000 and August 2003, 30 patients with malignant pleural mesothelioma received postoperative TM beginning 4 to 6 weeks after surgery at a dose adjusted to keep ceruloplasmin between 5 and 15 mg/dL). Time to progression was compared with the 55 stage I and II patients and 109 stage III patients previously treated with cytoreduction by one of us (H.P.).

RESULTS

The 30 patients (25 men, 5 women; 13 stage I and II, 17 stage III), median age 67 years (range, 49-81 years), remained on TM a median of 14.9 months (range, 2 to 57 months). All patients reached target ceruloplasmin levels at a mean of 34 +/- 2 days (95% confidence interval, 30 to 39 days), and vascular endothelial growth factor levels at baseline (ceruloplasmin = 45.2 +/- 2 mg/dL) decreased from 2,086 +/- 390 pg/mL to 1,250 +/- 712 pg/mL (p < 0.002) at target ceruloplasmin (13 +/- 2 mg/dL; p < 0.0001 from baseline). The time to progression for all stage I or II TM patients was 20 months whereas that of 55 stage I or II non-TM-treated patients was 10 months (p = 0.046 versus TM). No differences in time to progression for the stage III TM patents from surgery were seen (7 months).

CONCLUSIONS

Tetrathiomolybdate has antiangiogenic effects in malignant pleural mesothelioma patients after resection of gross disease, and exhibits minimal toxicity and comparable efficacy to previous multimodality trials. Tetrathiomolybdate should be evaluated for efficacy in combination with standard malignant pleural mesothelioma regimens, as well as for postsurgical maintenance therapy.

Impact of tumor-infiltrating T cells on survival in patients with malignant pleural mesothelioma

OBJECTIVE

The aim of the study was to determine the impact of tumor-infiltrating lymphocytes on survival in patients with malignant pleural mesothelioma treated with induction chemotherapy followed by extrapleural pneumonectomy.

METHODS

We performed an immunohistochemical analysis of 32 extrapleural pneumonectomy specimens to assess the distribution of T-cell subtypes (CD3(+), CD4(+), and CD8(+)), regulatory subtypes (CD25(+) and FOXP3(+)), and memory subtype (CD45RO(+)) within the tumor.

RESULTS

Patients with high levels of CD8(+) tumor-infiltrating lymphocytes demonstrated better survival than those with low levels (3-year survival: 83% vs 28%; P = .06). Moreover, high levels of CD8(+) tumor-infiltrating lymphocytes were associated with a lower incidence of mediastinal node disease (P = .004) and longer progression-free survival (P = .05). Higher levels of CD8(+) tumor-infiltrating lymphocytes were observed in patients treated with cisplatin and pemetrexed than in those treated with cisplatin and vinorelbine (P = .02). Patients presenting high levels of CD4(+) or CD25(+) tumor-infiltrating lymphocytes or low levels of CD45RO(+) also demonstrated a trend toward shorter survival. However, the presence of FOXP3(+) tumor-infiltrating lymphocytes did not affect survival. After multivariate adjustment, high levels of CD8(+) tumor-infiltrating lymphocytes remained an independent prognostic factor associated with delayed recurrence (hazard ratio = 0.38; confidence interval = 0.09-0.87; P = .02) and better survival (hazard ratio = 0.39; confidence interval = 0.09-0.89; P = .02).

CONCLUSION

The presence of high levels of CD8(+) tumor-infiltrating lymphocytes is associated with better prognosis in patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma. The stimulation of CD8(+) lymphocytes can be a potential therapeutic strategy to improve outcome.

The role of vaccine therapy in the treatment of melanoma

BACKGROUND

Melanoma is a tumour that is usually resistant to systemic therapy. Since it has been considered to be a highly immunogenic tumour, it has become an excellent target for the active specific immunotherapy. Vaccine therapy represents a novel approach to the treatment of melanoma.

OBJECTIVE

To evaluate different vaccines tested in stage III and/or IV melanoma patients.

METHODS

Systematic review of the published evidence on vaccine therapy in melanoma.

RESULTS

Melanoma vaccines can be classified into six groups: whole-cell vaccines, dendritic cell vaccines, peptide vaccines, ganglioside vaccines, DNA vaccines and viral vectors. The main characteristics of these vaccines including their advantages and disadvantages and the results from conducted trials are presented. Clinical responses to melanoma vaccines are still poor and currently there is no melanoma vaccine with a proven efficacy.

CONCLUSION

Vaccine therapy still remains an experimental therapy in patients with metastatic melanoma. Further research is required although a future therapy for advanced melanoma is probably a multimodal approach including vaccines, adjuvants and negative co-stimulatory blockade.

Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma

PURPOSE OF REVIEW

Extrapleural pneumonectomy is a radical and aggressive surgery that presents a great challenge to the thoracic anesthesiologist. This surgery is performed routinely by only a few centers in the world and this review represents our institution's experience in anesthetic care.

RECENT FINDINGS

Prominent among the developing multimodal treatment options is the combination of extrapleural pneumonectomy with intraoperative intracavitary hyperthermic chemotherapy. Outcome survival benefits have recently been demonstrated for the less completely cytoreductive pleurectomy procedure when combined with intraoperative intracavitary hyperthermic chemotherapy and trials are well under way for extrapleural pneumonectomy plus intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of extrapleural pneumonectomy is further impacted by these developments.

SUMMARY

Anesthetic management importantly contributes to containment of the perioperative complications of extrapleural pneumonectomy. An appreciation of the technical aspects and physiologic disruptions associated with extrapleural pneumonectomy is critical to effective management. While data on this relatively uncommon surgical procedure are scarce, some referral centers have accumulated extensive experience. This review summarizes relevant surgical aspects and anesthetic insights from the Brigham and Women's Hospital experience. Included are the anesthetic implications of intraoperative intracavitary hyperthermic chemotherapy in combination with extrapleural pneumonectomy - an emerging therapeutic option in the treatment of malignant pleural mesothelioma.

Multidisciplinary treatment of malignant pleural mesothelioma

The incidence of malignant pleural mesothelioma (MPM) is increasing worldwide, and is predicted to peak in the next 10-20 years. Difficulties in MPM diagnosis and staging, especially of early disease, have thwarted the development of a universally accepted therapeutic approach. Single modality therapies (surgery, radiotherapy, chemotherapy) have generally failed to significantly prolong patient survival. As a result, multimodality treatment regimens have been developed. Radical surgery with extrapleural pneumonectomy and adjuvant treatments has become the preferred option in early disease, but the benefits of such an aggressive approach have been questioned because of significant treatment-related morbidity and mortality. In the past few years, there have been several major advances in the management of patients with MPM, including more accurate staging and patient selection, improvements in surgical techniques and postoperative care, novel chemotherapy regimens with definite activity such as antifolate (pemetrexed or raltitrexed)-platinum combinations, and new radiotherapy techniques such as intensity-modulated radiation therapy. Induction chemotherapy followed by surgery and adjuvant radiotherapy has shown promising results. A number of molecular alterations occurring in MPM have been reported, providing broader insights into its biology and leading to the identification of new targets for therapy. However, currently available treatments still appear to have modest results. Further studies are needed to provide evidence-based recommendations for the treatment of early and advanced stages of this disease.