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Markowiak T, Ried M, Larisch C, Nowak D, Hofmann HS, Rakete S. Exposure to cisplatin in the operating room during hyperthermic intrathoracic chemotherapy. Int Arch Occup Environ Health 2022; 95:399-407. [PMID: 34191089 PMCID: PMC8795016 DOI: 10.1007/s00420-021-01738-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Hyperthermic intrathoracic chemotherapy (HITOC) is an additive, intraoperative treatment for selected malignant pleural tumors. To improve local tumor control, the thoracic cavity is perfused with a cisplatin-containing solution after surgical cytoreduction. Since cisplatin is probably carcinogenic to humans, potential contamination of surfaces and pathways of exposure should be systematically investigated to enable risk assessments for medical staff and thus derive specific recommendations for occupational safety. METHODS Wipe sampling was performed at pre-selected locations during and after ten HITOC procedures, including on the surgeon's gloves, for the quantitation of surface contaminations with cisplatin. After extraction of the samples with hydrochloric acid, platinum was determined as a marker for cisplatin by voltammetry. RESULTS High median concentrations of cytostatic drugs were detected on the surgeons' (1.73 pg Cis-Pt/cm2, IQR: 9.36 pg Cis-Pt/cm2) and perfusionists' (0.69 pg Cis-Pt/cm2, IQR: 1.73 pg Cis-Pt/cm2) gloves. The display of the perfusion device showed partially elevated levels of cisplatin up to 4.92 pg Cis-Pt/cm2 and thus could represent an origin of cross-contamination. In contrast, cisplatin levels on the floor surfaces in the area of the surgeon and the perfusion device or in the endobronchial tube were relatively low. CONCLUSION With a correct use of personal protective equipment and careful handling, intraoperative HITOC appears to be safe to perform with a low risk of occupational exposure to cisplatin.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christopher Larisch
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dennis Nowak
- Germany and Comprehensive Pneumology Center Munich, University Hospital, LMU Munich, Institute and Clinic for Occupational, Social and Environmental Medicine, Munich, Germany
- Comprehensive Pneumology Center Munich, German Center for Lung Research, Munich, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department of Thoracic Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Stefan Rakete
- Germany and Comprehensive Pneumology Center Munich, University Hospital, LMU Munich, Institute and Clinic for Occupational, Social and Environmental Medicine, Munich, Germany
- Comprehensive Pneumology Center Munich, German Center for Lung Research, Munich, Germany
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Molnar TF, Drozgyik A. Narrative review of theoretical considerations regarding HITHOC between past and future. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:954. [PMID: 34350269 PMCID: PMC8263867 DOI: 10.21037/atm-20-5855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 02/26/2021] [Indexed: 01/10/2023]
Abstract
Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.
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Affiliation(s)
- Tamas F Molnar
- Department of Operational Medicine, Faculty of Medicine, University of Pécs, Pécs, Hungary.,Chair of Surgery, Faculty of Medicine, University of Pécs/Dept Surgery, Aladar Petz University Teaching Hospital, Győr, Hungary
| | - Andras Drozgyik
- Chair of Surgery, Faculty of Medicine, University of Pécs/Dept Surgery, Aladar Petz University Teaching Hospital, Győr, Hungary
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Markowiak T, Koller M, Zeman F, Huppertz G, Hofmann HS, Ried M. Protocol of a retrospective, multicentre observational study on hyperthermic intrathoracic chemotherapy in Germany. BMJ Open 2020; 10:e041511. [PMID: 32690754 PMCID: PMC7375498 DOI: 10.1136/bmjopen-2020-041511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Objective of the 'German hyperthermic intrathoracic chemotherapy (HITOC) study' is to evaluate the HITOC as additional treatment after surgical cytoreduction for malignant pleural tumours. Even though HITOC is applied with increasing frequency, there is no standardised therapy protocol concerning the technique of HITOC, the selection as well as dosage of chemotherapeutic agents and perioperative management in order to provide a safe and comparable, standardised treatment regime. METHODS AND ANALYSIS This trial is a retrospective, multicentre observational study, which is funded by the German Research Foundation. Approximately 300 patients will be included. Four departments of thoracic surgery, which are performing the most HITOC procedures in Germany, are contributing to this study: Center for Thoracic Surgery at the University Hospital Regensburg, Thoracic Clinic Heidelberg of the University of Heidelberg, Center for Thoracic Surgery of the Hospital University of Munich and the Department of Thoracic Surgery at the University Hospital Freiburg. All patients who underwent surgical cytoreduction and subsequent HITOC at one of the four centres between starting the HITOC programme in 2008 and December 2019 will be included. Information on the performed HITOC will be obtained, focusing on the technique as well as the applied perfusion solution including the chemotherapeutic agent. Furthermore, parameters of the patient's postoperative recovery will be analysed to determine 30-day morbidity and mortality. ETHICS AND DISSEMINATION The approvals by the local ethics committee of the respective clinic and the three participating clinics have been obtained. The results will be presented in conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER German Clinical Trials Registry (DRKS00015012; Pre-results).
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Michael Koller
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Florian Zeman
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Gunnar Huppertz
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Michael Ried
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
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Markowiak T, Hofmann HS, Ried M. [Five Years PLEURATUMOR Register of the German Society of Thoracic Surgery]. Zentralbl Chir 2020; 146:321-328. [PMID: 32629507 DOI: 10.1055/a-1178-1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Since 01.01.2015, the nationwide "PLEURATUMOR Register of the German Society of Thoracic Surgery (DGT)" has documented the most relevant parameters of patients with primary and secondary malignant pleural diseases receiving thoracic surgery in Germany. This online database is intended to record both primary and recurrent diseases. In particular, the registry focuses on the documentation of patients with pleural carcinosis, malignant pleural mesothelioma and tumours of the thymus with pleural dissemination. METHODS A structured evaluation of all patients documented up to and including December 2019 was carried out. RESULTS At this time, 33 departments participated in the PLEURATUMOR Register and 670 patients have been recorded. Of these patients, 522 data sets were complete and 516 patients received surgical treatment. Most patients were documented in 2017 (n = 135; 26.2%), and in 2019 (n = 72; 14%). With 317 listed patients (61.4%), pleural carcinosis was the most frequently reported pleural tumour, followed by malignant pleural mesothelioma (n = 175; 33.9%) and thymoma/thymic carcinoma with pleural metastases (n = 11; 2.1%). The majority of patients (n = 499; 96.7%) were treated because of an initial manifestation. The most frequently documented procedure was VATS-talcum pleurodesis (n = 204; 39.5%). In 69 patients (13.4%) hyperthermic intrathoracic chemotherapy was performed after cytoreductive surgery. Postoperative complications occurred in 107 patients (20.7%); in 35 cases (6.8%) surgical revision was necessary. The overall 30-day mortality was 8.3% (n = 43). CONCLUSION Due to the consistent data entry of the participating clinics, a representative dataset of pleural tumour diseases could be recorded. In the future, we hope for consistent continuation of data entry and the initiation of register-based studies.
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Affiliation(s)
- Till Markowiak
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,Klinik für Thoraxchirurgie, KH Barmherzige Brüder Regensburg, Deutschland
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
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Abstract
In regional chemotherapy of the pleural space a differentiation is made between intrapleural hyperthermic perfusion (IHP) and hyperthermic intrathoracic chemotherapy (HITOC). The HITOC in particular is carried out as an additive procedure after surgical cytoreduction of the pleural tumor manifestation. The main indications are for malignant pleural mesothelioma and thymoma with pleural spread (stage IVa), whereas treatment of secondary pleural carcinomatosis is indicated only in selected patients suitable for resection followed by HITOC. Cisplatin is the standard chemotherapeutic agent and a concentration of 150-175 mg/m2 body surface area is recommended. Postoperative, HITOC-related complications (e.g. renal insufficiency) can be minimized by an adapted perioperative management. Safety measures should be accomplished adhered to for the protection of personnel. The aim of HITOC is to achieve a better local tumor control with a corresponding longer recurrence-free and overall survival.
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Affiliation(s)
- H-S Hofmann
- Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeningerstraße 86, 93049, Regensburg, Deutschland.
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
| | - M Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
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Kleontas A, Sioga A, Pandria N, Barbetakis N, Lazopoulos A, Katsikas I, Asteriou C, Paliouras D, Kamperis E, Ikonomou D, Papamitsou T, Filippou D, Destouni C, Ikonomou L, Zarogoulidis K, Papagiannopoulos K. Clinical factors affecting the survival of patients diagnosed with non-small cell lung cancer and metastatic malignant pleural effusion, treated with hyperthermic intrathoracic chemotherapy or chemical talc pleurodesis: a monocentric, prospective, randomized trial. J Thorac Dis 2019; 11:1788-1798. [PMID: 31285871 DOI: 10.21037/jtd.2019.05.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background There is a plethora of treatment algorithms for managing patients with malignant pleural effusions (MPEs), sharing many common points and principles. Our study aims to compare hyperthermic intrapleural chemotherapy (HITHOC) and talc pleurodesis (TALC), as treatment options for patients with non-small cell lung cancer (NSCLC) and metastatic MPE. Methods This prospective, randomized trial was conducted at a single thoracic surgery center, the "Theagenio" Cancer Institute, in Greece, under the identification code NCT01409551 and was completed. All 40 patients enrolled were adults with histologically proven metastatic, unilateral, MPE caused by NSCLC. Exclusion criteria included patients >80 years, trapped lung, and major comorbidities. Patients were randomly and equally assigned 1:1 to either HITHOC (group A) or TALC (group B) by video assisted thoracic surgery (VATS). The primary outcome was the median overall survival (OS) from trial intervention to death, while secondary outcome was the identification of clinical factors affecting the survival. Results The patients were followed up for 45 months. The OS of the full group was 8 months (95% CI: 7.046-8.954). Participants who underwent HITHOC had an OS of 8 months (95% CI: 7.141-8.859), whereas the participants of TALC had an OS of 9 months (95% CI: 7.546-10.454), with no significant difference between groups. Among fifty-four factors that were tested for their effects on survival, only TNM stage and creatinine values both preoperatively and 7 days postoperatively could be regarded as risk-factors for survival. Other recorded parameters, which had significant variance between the two groups, were urea levels, C-reactive protein, white blood cells and total in hospital length of stay (LOS). Conclusions Both HITHOC and TALC are equally effective and safe therapeutic options in treating patients with MPE and NSCLC with acceptable survival. The study revealed independent clinical risk factors influencing survival, which could be utilized as starting points for larger clinical studies. Keywords Pleurodesis; pleural effusion; malignant; carcinoma; non-small cell lung; hyperthermia.
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Affiliation(s)
- Athanasios Kleontas
- Department of Thoracic Surgery, European Interbalkan Medical Center of Thessaloniki, Thessaloniki, Greece
| | - Antonia Sioga
- Laboratory of Histology-Embryology, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niki Pandria
- Laboratory of Medical Physics, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Barbetakis
- Department of Thoracic Surgery, "Theagenio" Cancer Hospital of Thessaloniki, Thessaloniki, Greece
| | - Achilleas Lazopoulos
- Department of Thoracic Surgery, "Theagenio" Cancer Hospital of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Katsikas
- Department of Anesthesiology, Polyclinique Du Val De Loire, Nevers, France
| | - Christos Asteriou
- Department of Thoracic Surgery, Euromedica General Clinic of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Paliouras
- Department of Thoracic Surgery, "Theagenio" Cancer Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Kamperis
- Department of Radiotherapy, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Ikonomou
- Department of Thoracic Surgery, European Interbalkan Medical Center of Thessaloniki, Thessaloniki, Greece
| | - Theodora Papamitsou
- Laboratory of Histology-Embryology, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Filippou
- Department of Thoracic Surgery, European Interbalkan Medical Center of Thessaloniki, Thessaloniki, Greece
| | - Chariklia Destouni
- Laboratory of Cytology, "Theagenio" Cancer Hospital of Thessaloniki, Thessaloniki, Greece
| | - Louiza Ikonomou
- Laboratory of Histology-Embryology, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
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Markowiak T, Hofmann HS, Ried M. Intraoperative hypertherme intrathorakale Chemotherapie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0260-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patel MD, Damodaran D, Rangole A, Shaikh S, Shah K, Bagwade R, Bhatt A. Hyperthermic Intrathoracic Chemotherapy (HITHOC) for Pleural Malignancies-Experience from Indian Centers. Indian J Surg Oncol 2018; 10:91-98. [PMID: 30886500 DOI: 10.1007/s13193-018-0859-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/04/2018] [Indexed: 12/20/2022] Open
Abstract
Hyperthermic intrathoracic chemotherapy (HITHOC) has been used in addition to radical surgery for primary and secondary pleural malignancies to improve local control, prolong survival, and improve the quality of life. This study was performed to study the indications, methodology, perioperative outcomes, and survival in patients undergoing HITHOC at Indian centers. A retrospective analysis of prospectively collected demographic and clinical data, perioperative and survival data of patients undergoing surgery with or without HITHOC was performed. From January 2011 to May 2018, seven patients underwent pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) with HITHOC and four had P/D or EPP alone at three Indian centers. P/D was performed in two and EPP in nine patients. The primary tumor was pleural mesothelioma in eight, metastases from thymoma in one, germ cell tumor in one, and solitary fibrous tumor of the pleura in one. HITHOC was performed using cisplatin. Grade 3-4 complications were seen in one patient in the HITHOC group and none in the non-HITHOC group, and one patient in the non-HITHOC group died of complications. At a median follow-up of 9 months, five patients of the HITHOC group were alive, four without recurrence, and one with recurrence. One patient in the non-HITHOC group was alive and disease-free at 24 months, and two died of progression at 18 and 36 months. HITHOC can be performed without increasing the morbidity of P/D or EPP. Most of these patients require multimodality treatment and are best managed by multidisciplinary teams.
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Affiliation(s)
- Mahesh D Patel
- Department of Surgical Oncology, Zydus Hospital, Zydus hospital road, SG highway, Thaltej, Ahmedabad, 380054 India
| | - Dileep Damodaran
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Calicut, India
| | - Ashvin Rangole
- Department of Surgical Oncology, CHL, CBCC Cancer Centre, Indore, India
| | - Sakina Shaikh
- Department of Surgical Oncology, Zydus Hospital, Zydus hospital road, SG highway, Thaltej, Ahmedabad, 380054 India
| | - Kairav Shah
- Department of Anaesthesiology, Zydus Hospital, Ahmedabad, India
| | | | - Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Zydus hospital road, SG highway, Thaltej, Ahmedabad, 380054 India
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