Types of Mesothelioma Chemotherapy

What Are the Types of Chemotherapy for Mesothelioma?

The types of mesothelioma chemotherapy differ in how chemotherapy is delivered into the body. The different types are:

• Systemic or intravenous chemotherapy
• Heated intraoperative chemotherapy
• Dwell chemotherapy

Most patients can receive systemic chemotherapy. Not all patients are eligible for heated intraoperative chemotherapy or dwell chemotherapy.

Two other types of chemotherapy are injection and oral delivery. In February 2020, the U.S. Food and Drug Administration (FDA) approved an injection delivery method of the mesothelioma chemotherapy drug pemetrexed. This is a type of systemic (intravenous) chemotherapy that delivers the drugs quicker than standard chemotherapy.

Oral delivery of chemotherapy medication is still in experimental stages.

Systemic Chemotherapy (Intravenous Chemotherapy)

Systemic chemotherapy is delivered through an IV into a vein or port. The chemotherapy drugs travel through the bloodstream to stop tumor growth and decrease tumor size.

Systemic chemotherapy can also unfortunately damage healthy tissue and attack the blood cells. This can cause side effects like nausea, vomiting, fatigue and loss of appetite.

Systemic chemotherapy is offered at all mesothelioma cancer centers of excellence in the United States.

Chemotherapy Injection

Chemotherapy injection sends chemotherapy drugs into the body in less time than systemic chemotherapy. The FDA approved injection of pemetrexed for malignant mesothelioma. This is called PEMFEXY.

It’s unknown how accessible this chemotherapy treatment is for mesothelioma patients. Many cancer centers may prefer systemic chemotherapy.

Heated Intraoperative Chemotherapy (HIOC)

Heated intraoperative chemotherapy, or HIOC for short, is a type of chemoperfusion. Doctors deliver heated liquid chemotherapy drugs into the chest cavity or abdominal cavity. These drugs are delivered immediately after mesothelioma surgery concludes, while the doctors have direct access to the tumors via the open chest or abdomen.

There are two types of HIOC and they are both used with surgery:

• Hyperthermic intraperitoneal chemotherapy (HIPEC), for peritoneal mesothelioma
• Hyperthermic intrathoracic chemotherapy (HITHOC), for pleural mesothelioma

Intraoperative chemotherapy is offered at specialized cancer centers offering mesothelioma treatment. A few of the high-profile centers are:

• Moffitt Cancer Center in Tampa, Florida
• Brigham and Women’s Hospital in Boston, Massachusetts
• Wake Forest Baptist Cancer Center in North Carolina
• Baylor St. Luke’s Medical Center in Houston, Texas
• University of Pittsburgh Medical Center in Pennsylvania

Dwell Chemotherapy

Dwell chemotherapy is an experimental type of treatment for mesothelioma. It involves infusing chemotherapy directly into the abdominal cavity. Doctors leave the drugs in place for an extended amount of time. The prolonged exposure to the chemotherapy drugs improves their ability to wash tumors and kill cancer cells.

Doctors place two catheters, or ports, in the patient’s body. These ports deliver the drugs directly into the affected area, such as the peritoneal cavity or abdominal cavity. Since the chemotherapy doesn’t travel through the bloodstream, the side effects are limited.

Dwell chemotherapy is limited to clinical trials and specialized cancer centers. We suggest you contact a mesothelioma patient advocate for recommendations on treatment centers.

NIPEC

One type of dwell chemotherapy is normothermic intraperitoneal chemotherapy (NIPEC), primarily used for peritoneal mesothelioma. This is a long-term type of chemotherapy. Doctors deliver a room-temperature chemotherapy solution into the abdominal cavity.

NIPEC involves leaving ports in the patient’s body following cytoreductive surgery. Doctors deliver the chemotherapy drug paclitaxel through the ports and leave it in the affected area for multiple days. This therapy is different from HIPEC, which involves draining the drugs within a couple hours.

NIPEC led to long-term survival in six consecutive cases of peritoneal mesothelioma treated by Dr. Paul Sugarbaker. While he’s now retired, Dr. Sugarbaker was a peritoneal mesothelioma specialist and surgeon. He had six patients in a row reach at least eight years survival, largely due to dwell chemotherapy.

Transarterial Chemoperfusion

Transarterial chemoperfusion delivers high-volume chemotherapy drugs directly to diseased tissue. Transarterial chemotherapy avoids the bloodstream, which limits side effects.

Doctors deliver a combination of drugs. In the above study, they used cisplatin, methotrexate and gemcitabine. They are injected into the thoracic artery and possibly the internal mammary artery, which supplies the pleura (where pleural mesothelioma forms) with oxygen‑rich blood.

Transarterial chemoperfusion sessions last two hours.

Oral Delivery of Chemotherapy

Oral chemotherapy pills are still in testing for malignant mesothelioma. One such medication, olaparib, sold under the brand name Lynparza, treats specific genetic damages.

Mesothelioma involves damaged genes from exposure to asbestos. Olaparib is a poly polymerase enzyme inhibitor. It has three enzymes helping with DNA transcription and repair and can improve cancer cell destruction.

This type of chemotherapy is limited to clinical trials. It’s not a widely accessible option yet for people with mesothelioma.

When to Use Chemotherapy for Mesothelioma

Doctors and cancer centers have varying views on when to use chemotherapy for mesothelioma. The main options are whether to use chemotherapy before, during or after surgery:

• The traditional thought is use chemotherapy after surgery (adjuvant chemotherapy)
• Some doctors may prefer chemotherapy during surgery (intraoperative chemotherapy)
• A few specialists believe the best approach is chemotherapy before surgery (neoadjuvant chemotherapy)

Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy refers to using the treatment before surgery. It’s primarily for patients with an aggressive cancer (stage 3 or stage 4).

Doctors use neoadjuvant chemotherapy to contain or shrink tumors prior to surgery. This tactic hopefully makes resection easier for the experienced surgeon. It can also “downstage” patients to a more manageable diagnosis.

Intraoperative Chemotherapy

Intraoperative chemotherapy makes the most of direct access to the tumor environment through surgery. Doctors deliver heated liquid chemotherapy to wash the chest or abdomen of standalone tumors in the area.

Intraoperative chemotherapy is an option for both pleural and peritoneal mesothelioma. It can be used with all three aggressive surgeries:

• Extrapleural pneumonectomy
• Pleurectomy with decortication
• Cytoreductive surgery

For pleural mesothelioma, the survival stats range from 2-4 years. One from 2019 had a median survival of 42 months after pleurectomy with decortication.

Adjuvant Chemotherapy

Adjuvant chemotherapy refers to using the treatment after surgery. The goal is to contain what’s left of the disease following the operation. Since mesothelioma grows and spreads as separate tumors, complete resection is near-impossible. Chemotherapy is an option to control the remaining cancer cells.

Adjuvant chemotherapy includes many types of delivery:

• Systemic/intravenous chemotherapy
• Oral chemotherapy
• Injection
• Dwell chemotherapy

Many studies report favorable survival stats from systemic chemotherapy after surgery. Memorial Sloan Kettering Cancer Center paired pleurectomy with decortication and systemic chemotherapy. The median survival was 32 months.