Peritoneal Mesothelioma Introduction
Peritoneal Mesothelioma
Introduction
Peritoneal mesothelioma is an extremely rare cancer arising from the peritoneum or lining of the abdomen itself. It represents 7 to 10% of patients with a mesothelioma diagnosis and is the second most common site of origin after the pleura .
The majority of patients with peritoneal mesothelioma are not suitable for surgery and the mainstay of treatment is systemic chemotherapy. In carefully selected patients treatment for this primary peritoneal tumor is aimed at removal of all visible disease by a combination of peritonectomies (stripping of the peritoneal lining of the abdomen) and removal of affected organs, termed cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC) to destroy any remaining cancer cells ( also known as the Sugarbaker procedure after Paul Sugarbaker who pioneered the technique). Patients with disease in the omentum, enlarged ovaries from tumour or recurrent ascites (fluid in the abdomen) may benefit from major tumor debulking and HIPEC to help with symptoms if surgeons do not think they can remove all of the disease.
Who will benefit from CRS & HIPEC?
Patient selection for CRS and HIPEC is complex, including CT imaging and staging laparoscopy (keyhole surgery to assess the extent of mesothelioma); unfortunately, the majority of patients are considered unsuitable for surgery and will be treated with systemic chemotherapy and best supportive care. CRS and HIPEC is performed in a small group of patients for either of 2 goals: to remove all visible disease (complete cytoreduction) which may help people live longer ; or to achieve symptom relief (including drainage of fluid inside the abdomen and bowel obstruction) by performing a major tumour debulking.
Surgery can take 8 or 9 hours on average and patients must be fit enough to withstand it. More information can be found on the PMI Basingstoke website.
Commissioning for Mesothelioma
In July 2015, NHS England announced their investment decisions for certain specialised services as part of the annual commissioning round. This included the decision not to routinely commission Cytoreductive Surgery + HIPEC for peritoneal mesothelioma.
Basingstoke made the decision to continue to honour the care pathways to completion for those patients already referred to the service and to continue to provide this service where clinically indicated.
National Peritoneal Mesothelioma MDT (NPMMDT)
The Peritoneal Malignancy Institute Basingstoke initiated a monthly PM MDT video-conference incorporating the North Hampshire Hospital in Basingstoke, Good Hope Hospital in Birmingham and Mater Hospital in Dublin.
Birmingham and The Mater Hospital in Dublin. Core members included surgeons, radiologists, specialist nurses and pathologists. Oncologists with an interest in Peritoneal Mesothelioma attend when possible. The aim of the NPMMDT was to plan optimal treatment for these patients and record outcomes to provide evidence of the benefits of centralisation and the need for National Funding of a peritoneal mesothelioma service.
A dedicated Peritoneal Mesothelioma Nurse Specialist was appointed, funded by Mesothelioma UK to co-ordinate the NPMMDT, support patients, develop consistent patient information, develop and deliver appropriate training and assist the follow up of all patients referred to the NPMMDT. Basingstoke & North Hampshire Hospital funded a dedicated NPMMDT co-ordinator. All patients with PM from UK and Ireland referred to any of the peritoneal malignancy units were discussed. Case reviews focused on clinical details, radiological imaging and review of histology. Discussions explored clinical presentation, symptoms, diagnostic pathways and histological confirmation aiming to provide treatment recommendations. All centres could view radiological images and speak with and visualise all participants.
The first National PM MDT was held in March 2016 . Centres agreed that surgical treatment would be performed at one dedicated centre (PMI Basingstoke) for UK patients in order to provide consistent data on operative outcomes and cost. Patients residing in the Republic of Ireland could undergo treatment in Dublin.
In total, 34 National PM MDT meetings incorporated review of 155 new patients with PM (79 female; 76 male) between March 2016 and December 2018. Overall, 35 patients were discussed more than once. Surgical outpatient assessment was recommended in 40/155 patients and diagnostic laparoscopy in 12/155 patients. This is an important development in management of patients with peritoneal mesothelioma.
The Future
Exciting developments are on the horizon for patients with peritoneal mesothelioma who may not be suitable for the Sugrabaker procedure because their disease is too extensive or involveing the small bowel surfaces. Pressurised Intraperitoneal Aerosol Chemotherapy (PIPAC) is an experimental treatment that involves spraying chemotherapy under pressure inside the abdomen to kill mesothelioma cells. A trial (MESOTIP) is underway in France and we hope to start a similar trail here in the UK soon. Watch this space as we will need your help!
Faheez Mohamed MD FRCS
Consultant Surgeon
Clinical Director General Surgery, Basingstoke
Introduction
Peritoneal mesothelioma is an extremely rare cancer arising from the peritoneum or lining of the abdomen itself. It represents 7 to 10% of patients with a mesothelioma diagnosis and is the second most common site of origin after the pleura .
The majority of patients with peritoneal mesothelioma are not suitable for surgery and the mainstay of treatment is systemic chemotherapy. In carefully selected patients treatment for this primary peritoneal tumor is aimed at removal of all visible disease by a combination of peritonectomies (stripping of the peritoneal lining of the abdomen) and removal of affected organs, termed cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC) to destroy any remaining cancer cells ( also known as the Sugarbaker procedure after Paul Sugarbaker who pioneered the technique). Patients with disease in the omentum, enlarged ovaries from tumour or recurrent ascites (fluid in the abdomen) may benefit from major tumor debulking and HIPEC to help with symptoms if surgeons do not think they can remove all of the disease.
Who will benefit from CRS & HIPEC?
Patient selection for CRS and HIPEC is complex, including CT imaging and staging laparoscopy (keyhole surgery to assess the extent of mesothelioma); unfortunately, the majority of patients are considered unsuitable for surgery and will be treated with systemic chemotherapy and best supportive care. CRS and HIPEC is performed in a small group of patients for either of 2 goals: to remove all visible disease (complete cytoreduction) which may help people live longer ; or to achieve symptom relief (including drainage of fluid inside the abdomen and bowel obstruction) by performing a major tumour debulking.
Surgery can take 8 or 9 hours on average and patients must be fit enough to withstand it. More information can be found on the PMI Basingstoke website.
Commissioning for Mesothelioma
In July 2015, NHS England announced their investment decisions for certain specialised services as part of the annual commissioning round. This included the decision not to routinely commission Cytoreductive Surgery + HIPEC for peritoneal mesothelioma.
Basingstoke made the decision to continue to honour the care pathways to completion for those patients already referred to the service and to continue to provide this service where clinically indicated.
National Peritoneal Mesothelioma MDT (NPMMDT)
The Peritoneal Malignancy Institute Basingstoke initiated a monthly PM MDT video-conference incorporating the North Hampshire Hospital in Basingstoke, Good Hope Hospital in Birmingham and Mater Hospital in Dublin.
Birmingham and The Mater Hospital in Dublin. Core members included surgeons, radiologists, specialist nurses and pathologists. Oncologists with an interest in Peritoneal Mesothelioma attend when possible. The aim of the NPMMDT was to plan optimal treatment for these patients and record outcomes to provide evidence of the benefits of centralisation and the need for National Funding of a peritoneal mesothelioma service.
A dedicated Peritoneal Mesothelioma Nurse Specialist was appointed, funded by Mesothelioma UK to co-ordinate the NPMMDT, support patients, develop consistent patient information, develop and deliver appropriate training and assist the follow up of all patients referred to the NPMMDT. Basingstoke & North Hampshire Hospital funded a dedicated NPMMDT co-ordinator. All patients with PM from UK and Ireland referred to any of the peritoneal malignancy units were discussed. Case reviews focused on clinical details, radiological imaging and review of histology. Discussions explored clinical presentation, symptoms, diagnostic pathways and histological confirmation aiming to provide treatment recommendations. All centres could view radiological images and speak with and visualise all participants.
The first National PM MDT was held in March 2016 . Centres agreed that surgical treatment would be performed at one dedicated centre (PMI Basingstoke) for UK patients in order to provide consistent data on operative outcomes and cost. Patients residing in the Republic of Ireland could undergo treatment in Dublin.
In total, 34 National PM MDT meetings incorporated review of 155 new patients with PM (79 female; 76 male) between March 2016 and December 2018. Overall, 35 patients were discussed more than once. Surgical outpatient assessment was recommended in 40/155 patients and diagnostic laparoscopy in 12/155 patients. This is an important development in management of patients with peritoneal mesothelioma.
The Future
Exciting developments are on the horizon for patients with peritoneal mesothelioma who may not be suitable for the Sugrabaker procedure because their disease is too extensive or involveing the small bowel surfaces. Pressurised Intraperitoneal Aerosol Chemotherapy (PIPAC) is an experimental treatment that involves spraying chemotherapy under pressure inside the abdomen to kill mesothelioma cells. A trial (MESOTIP) is underway in France and we hope to start a similar trail here in the UK soon. Watch this space as we will need your help!
Faheez Mohamed MD FRCS
Consultant Surgeon
Clinical Director General Surgery, Basingstoke