Bidirectional chemotherapy allowing surgery and HIPEC for malignant peritoneal mesothelioma.

BACKGROUND: This case report aims to describe the impact of the bidirectional chemotherapy (BDC) on resecability for initially unresectable malignant peritoneal mesothelioma (MPM).
METHODS: We report a case of 55-year-old male with the diagnosis of initially unresecable MPM. The BDC combined intravenous (IV) chemotherapy (Cisplatin-Pemetrexed) and intra peritoneal (IP) chemotherapy (Cisplatin). The response to chemotherapy was assessed by CT - scan and laparoscopy.
RESULTS: Initial evaluation classed the disease as unresecable with PCI at 39. At the reevaluation, CT - scan and laparoscopy showed a macroscopic response, allowing surgery consisting of cytoreductive surgery and hyperthermic intra peritoneal chemotherapy (Doxorubicin and Cisplatin).
CONCLUSIONS: BDC (IV and IP) has promising results and allows to undergo surgery for selected patients with borderline or initially unresectable MPM.

We report a case of 55-year-old male with the diagnosis of malignant peritoneal mesothelioma (MPM). Initial evaluation with CT-scan and laparoscopy reveals unresectable peritoneal carcinomatosis with PCI at 39 with thickened omentum (star), small bowel (2 stars) and parietal peritoneum (dash-arrow) deposit, ascitis (plane-arrow) (Figure 1A, B). Bidirectional chemotherapy (BDC) has been performed after three cycles of intravenous (IV) CISPLATIN – PEMETREXED, with intensification combining three cycles of IV PEMETREXED with intraperitoneal (IP) CISPLATIN (Figure 2). At reevaluation, PCI was still at 39 with a macroscopic response (Figure 3A, B). The peritoneal disease was thinner allowing a complete CRS with DOXORUBICIN/CISPLATIN based-HIPEC.

Figure 1:

CT scan (A) and laparoscopic evaluation (B) at diagnosis of malignant peritoneal mesothelioma.

Figure 2:

Detailed schedule of chemotherapy.

Figure 3:

CT scan (A) and laparoscopic evaluation (B) after bi–directional chemotherapy.

BDC allowed selecting patients with initially unresectable MPM to undergo surgery and increase the overall survival (OS) [1, 2]. New IP delivery with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) reported promising results in palliative treatment of MMP [3] and is under evaluation to increase OS and secondary resectability of huge MMP (Clinical Trials NCT03875144).