title: Two-stage operative cytoreduction and intraperitoneal chemotherapy for diffuse malignant peritoneal mesothelioma: Operative morbidity and mortality in phase I and II trials.
abstract: OBJECTIVE
  The standard of care for diffuse malignant peritoneal mesothelioma involves operative cytoreduction and intraperitoneal chemotherapy. Most centers favor aggressive operative cytoreduction, accepting high morbidity and mortality. In our trials, patients underwent less extensive cytoreduction followed by prolonged intraperitoneal chemotherapy. Patients underwent a second cytoreduction with heated intraperitoneal chemotherapy. We hypothesized this would result in lower operative morbidity and mortality with similar survival.
  
  
  METHODS
  Hospital records, discharge summaries, microbiology, radiography, and office records were retrospectively reviewed to supplement a prospective database. 30-day morbidity and mortality were categorized, and classified according to the Clavien methodology.
  
  
  RESULTS
  47 first and 39 second operations were performed with 13% and 26% morbidity, respectively. Mortality was 2%. Infections comprised 59% of the morbidity. Inclusive of both operations, formal peritonectomy was performed in 16% of patients, resection of isolated lesions in less than half, and only 19% had a visceral organs other than the spleen resected. At the completion of the protocol, only 3% of patients had visible intraperitoneal disease. The mean total length of stay for both operations combined was 16 ± 23 days. Overall median survival was 54.9 months, and median survival for the epithelioid subtype was 70.2 months.
  
  
  CONCLUSIONS
  A two-stage cytoreduction with intraperitoneal chemotherapy offers median survival comparable to one-stage protocols, with relatively low morbidity, mortality, visceral resections and length of stay despite two operations. This series supports that our protocol is a feasible and safe approach.
authors.affiliation: Department of Surgery, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, New York 10032, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Kluger
authors.forename: R N
authors.initials: RN
authors.lastname: Taub
authors.forename: M
authors.initials: M
authors.lastname: Hesdorffer
authors.forename: Z
authors.initials: Z
authors.lastname: Jin
authors.forename: J A
authors.initials: JA
authors.lastname: Chabot
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D001707:Biopsy, Needle; D002423:Cause of Death; D003131:Combined Modality Therapy; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007274:Injections, Intraperitoneal; D053208:Kaplan-Meier Estimate; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008654:Mesothelioma / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D009519:New York City; D010534:Peritoneal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D011379:Prognosis; D011446:Prospective Studies; D012086:Reoperation / Q000379:methods; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome