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Peritoneal mesothelioma is the second most common type of this rare form of cancer. Pleural mesothelioma is the most common, affecting the the mesothelium of the chest cavity. Peritoneal mesothelioma, however, is the cancer of the tissue lining the abdominal cavity. As with its more common counterpart, this type of mesothelioma is difficult to treat. Patients who receive a diagnosis rarely have a good prognosis.
The surgical treatment option that provides the best opportunity to increase survival time, is a peritonectomy. This is a surgical procedure that removes all or some of the peritoneum, the lining of the abdominal cavity. Survival benefit can be improved when surgeons add the instillation of heated chemotherapy into the abdominal cavity, called hyperthermic intraperitoneal chemotherapy, or HIPEC. When used together, these strategies reduce symptoms, extend life expectancy, and increase the duration before the cancer returns.
The peritoneum is the part of the mesothelium that lines the abdominal cavity and the organs inside. Mesothelioma is most strongly associated with inhaling tiny asbestos fibers, which is why the pleural form of the cancer is most common. However, those fibers may also be accidentally ingested. They may also migrate from the chest cavity to the abdominal cavity, causing tissue damage that leads to peritoneal mesothelioma.
Survival rates for peritoneal mesothelioma tend to be poor. About one quarter of people diagnosed will live for three or more years. Treatment can extend life expectancy. If the cancer is diagnosed early, there is a small chance of a cure or remission. Perhaps the best way to achieve remission is by surgically removing cancerous tissues.
What Is a Peritonectomy?
Peritonectomy is a form of cytoreductive surgery. Cytoreductive surgery is any surgical procedure that removes cancerous tissue. The term peritonectomy refers specifically to removal of the peritoneum. However, this surgery may also remove parts of organs with cancerous tissue. Organs that may be affected are the intestines, gall bladder, liver, stomach, pancreas, or spleen.
The surgery is intended to relieve symptoms, slow progression, and achieve remission, although the latter is not always possible. To improve the odds of remission and reduce the chance of a recurrence after surgery, the procedure is often combined with chemotherapy. This combination can eliminate cancer cells the surgeon was not able to safely remove or were too small to visualize during surgery.
Hyperthermic Intraperitoneal Chemotherapy
For peritoneal mesothelioma, HIPEC is often used after surgery. HIPEC is an innovative chemotherapy method that injects heated chemotherapy drugs directly into the abdominal cavity. This differs from traditional chemotherapy which administers drugs intravenously, allowing them to curculate through the entire body.
HIPEC is proven more effective for treating peritoneal mesothelioma than the standard chemotherapy. Some studies found that treatment with HIPEC gives patients a 50 percent chance of surviving five years. This is a major achievement for treating a disease that was previously so difficult to manage. The increased survival times after HIPEC are associated with he epithelial subtype of mesothelioma.
Benefits of Peritonectomy
There are several goals of peritonectomy followed by HIPEC. These procedures tend to be palliative, meaning they aim to reduce symptoms extend survival times, and achieve the best chance at long term remission. Curing peritoneal mesothelioma is generally not a realistic goal, however, those with early-stage mesothelioma have a better chance for this treatment combination resulting in long-term remission.
For most mesothelioma patients, this surgery is used to extend life. For those with advanced cancer, a benefit of peritnectomy is relief from symptoms. The removal or reduction of tumors in the abdomen can reduce pain and swelling, allowing the patient to feel more comfortable.
Risks and Complications
Peritonectomy followed by HIPEC is major surgery. While it may be less risky than radical surgeries used to treat pleural mesothelioma, it can still have major complications. Older patients or those with complex medical conditions are more likely to have complications from the surgery, yet anyone is susceptible.
Possible complications include fistulas in the bowels, bile leaks, and excessive bleeding. Other complications are the same as those seen with any major surgery, including blood clots and infections. It is possible a patient will struggle to recover from this surgery only to have the cancer recur soon after.
Organ Damage and the Need for an Ostomy
Anytime there is an operation in the abdominal cavity, there is a small risk of injury to the bowel or urinary tract. If there is injury or obvious tumor involvement prohibiting the surgical repair, an ostomy may be necessary. An ostomy is a surgical procedure that diverts the digestive or urinary tract to the outside of the body. The procedure creates an opening, called a stoma, that links the small intestine, large intestine (colon), or ureter to the outside of the body, bypassing the normal routes through which waste is expelled from the body.
Ostomies are typically done when the bladder or bowels cannot function normally due to disease. In rare cases, organ damage may occur as a complication of surgery. It is not a common complication, but any abdominal surgery, including a peritonectomy, may result in damage that requires an ostomy. The ostomy may be permanent or may only be temporary to allow affected tissue to heal.
Living with an ostomy presents many challenges. Patients need an ostomy bag to collect feces or urine. The stoma does not have a valve to shut off flow, the patient is unable to control when waste passes from the body. Specialty ostomy nurses are an invaluable resource to provide a plan for management including problem solving for any issues that arise. This can be emotionally difficult to deal with complex body image changes. These can either be temporary or permanent. If a reversal is possible, it will require another surgery.
Recovery from peritonectomy varies by patient. Younger, healthier patients, as well as those in earlier cancer stages typically recover more quickly and with fewer complications. Due to possible complications, patients must remain in the hospital after surgery and HIPEC chemotherapy. Patients may receive intravenous medications and fluids after surgery. Initially, there is often a tube to drain the stomach until normal bowel function returns. The goal is to return to a modified diet as soon as possible. Having a nutritionist can be very helpful to provide new dietary recommendations. Once patients go home they will be on modified activity until fully recovered.
Peritoneal mesothelioma is a serious and aggressive cancer. Prognosis for this illness is overall poor. However, innovative treatment options have increased survival times. Cytoreductive peritonectomy surgery followed by HIPEC is an effective way to help patients live longer. For some, this procedure may even provide a cure. If you are facing treatment for peritoneal mesothelioma, know your options. Your medical team can help you understand the risks and benefits of a peritonectomy.
Page Medically Reviewed and Edited by Anne Courtney, AOCNP, DNP
Anne Courtney has a Doctor of Nursing Practice degree and is an Advanced Oncology Certified Nurse Practitioner. She has years of oncology experience working with patients with malignant mesothelioma, as well as other types of cancer. Dr. Courtney currently works at University of Texas LIVESTRONG Cancer Institutes.