Dr. Ahmet F. Işık talks about pleural mesothelioma, HITHOC, and thoracic surgery in Gaziantep, Turkey

updates on the on-going HITHOC project, war surgery, foreign body obstructions and bronchoscopy for infants


Gaziantep, Southeastern Anatolia 


It’s been over a year since I first read Dr. Isik’s work on treating pleural mesothelioma.  Since that time, Dr. Işik has continued his research into HITHOC and has now enrolled over 79 patients into the hyperthermic treatment group including one of the patients I met during my visit.  (There are 29 surviving patients in the study, 13 in the mesothelioma group, the remainder are secondary pleural cancers.).

(If you are a patient seeking treatment, or would like more information about Dr. Isik (or Dr. Gonzalez Rivas, Dr. Sihoe or any of the other modern Masters of thoracic surgery), we  are happy to assist you.  Contact me at kristin@americanphysiciansnetwork.org

First impressions are deceiving

I don’t know what I expected Gaziantep to look like as one of the world’s oldest cities, but from the moment the airplane begins its descent into a beige dust cloud, to the desolate brush and dirt of the airport outside the city, it isn’t what I expected.  Much of the antiquity of the biblical city of Antiochia has been replaced by a bustling modern city.  Historic ruins and ancient Roman roads marking this as part of the original Silk Road are conspicuous, only by their scarcity.

modern Gaziatep is featureless at first glance
modern Gaziantep is featureless at first glance

There are a handful of museums and monuments to the area’s rich history, but like the new name of Gaziantep (replacing Antep after the first world war), Turkey’s sixth largest city is modern; a collection of traffic and squat square buildings of post-modern architecture.


The city is also a mosaic of people.  There are groups of foreign journalists in the lobby of our hotel, and convoys of United Nations vehicles cruising the streets.  Crowds of Syrian children play in the park, calling out in Arabic to their parents resting on the benches nearby.  There is a smattering of Americans and English speakers interspersed, many are college students and other foreign aid workers on humanitarian missions to help alleviate the strain caused by large numbers of people displaced by the Syrian civil war.

Gaziantep is famed for their copper work
Gaziantep is famed for their copper work

But like a mosaic, there is always more to see, the closer you look.  For me, as I look closer, I just want to see more.  I feel the same about Dr. Elbeyli’s thoracic surgery department.

The closer you look, the more you see. photo courtesy of wiki-commons
The closer you look, the more you see.
photo courtesy of wiki-commons

The border (and the largest Syrian city of Aleppo) lies just to the south – and the impact of the Islāmic militants is felt throughout the region.  No where is this more evident than at the local university hospital, where I meet Dr. Ahmet Işık and the Chief of Thoracic Surgery, Dr. Levent Elbeyli.

with Dr. Elbeyli (left) and Dr. Isik
with Dr. Elbeyli (left) and Dr. Isik

Dr. Ahmet Feridun Işık

I like Dr. Işık immediately.  He is friendly and appears genuinely interested by my visit.  He’s from Giresun in the Black Sea region of northern  Anatolia of Turkey.  He attended medical school at Ankara University and completed his thoracic surgery training in Ankara before going to Adiyaman State Hospital in the bordering Turkish province of Adiyaman in southeastern Turkey.

He was an associate professor of thoracic surgery at Yuzuncu Yil University in the far eastern province of Van, Turkey before coming to Gaziantep in 2005.  He became a full professor at the University of Gaziantep in 2013.  In additional to authoring and contributing to his own publications, he also served as a reviewer for the Edorium series of open access journals.

It helps that his English is miles better than my non-existent Turkish.  (Reading about the Turkish language in phrase books is one thing, pronouncing words correctly is another.)

He doesn’t seem to mind my questions tumbling out one after another.  I’d like to be the cool, sophisticated visitor, but I’ve been waiting so long to ask some of these questions – and frankly, I am just excited to be there.

Dead-ends in medicine

There are a lot of “dead ends” in medicine – treatments that at first appear promising, but then end up being either impractical or ineffective.  In fact, for the first ten years of HIPEC, most surgeons dismissed it as a ‘dead-end’ treatment; the surgery was too radical and mortality too high.  But researchers kept trying experimental protocols; tweaking medications (less toxic) and procedures – and finding the right patients (not too frail prior to surgery) – and the literature shifted; from a largely useless ‘last ditch’ salvage procedure to a large, but potentially life-saving treatment. HITHOC is HIPEC in another color…

So I fire away –

Since our last post about Dr. Işık – he has performed several more cases of HITHOC on patients with pleural mesothelioma, pleural based cancers and advanced lung cancers.  He now has 79 patients in the HITHOC treatment group.  He has been receiving patients from all over Turkey, including Istanbul to be evaluated for eligibility for this procedure.  While the majority of patients are referred by their oncologists, others come to Gaziantep after reading about Dr. Işık on the internet.

None of the original patients (from 2009) are still alive, but their survival still exceeded all expectations, with 13 patients (of 14 HITHOC patients) living 24 to 36 months after the procedure.  (I don’t mean to be vague – but I was asking some of these questions in the operating room and I forgot to stuff my little notebook in my scrub pocket.)

While much of the literature surrounding the procedure cites renal failure as one of the major complications of the procedure, Dr. Işık has had one case of renal failure requiring dialysis.  Any other instances of elevated creatinine were mild and transient.  He doesn’t use any chemical renal prophylaxis but he does use fluid rehydration to limit nephrotoxicity.

He reports that while many surgeons consider sarcomas to be a contraindication to this procedure, he has had good outcomes with these patients.

He does state that diaphragmatic involvement in mesothelioma is an absolute contraindication because while the diaphragm can be resected / patched etc, it is almost impossible to guarantee or absolutely prevent the seeding of microscopic cancer cells from the diaphragm to the abdominal cavity – which increases the risk of disseminated disease.

He still uses Cisplatin – since that is what the original HITHOC researchers were using, but he uses a slightly higher dose of 300mg.  He’d like to do some prospective studies utilizing HITHOC (these have all been retrospective in nature – comparing today’s patients with past patients that received PDD and pleurodesis for similar conditions).  Prospective studies would allow him to better match his patients and to compare treatments head to head.  It would also allow him to compare different techniques or chemotherapeutic agents.

Unfortunately, as he explained, many of these types of studies of ineligible for government funding in Turkey because the government doesn’t want to pay for experimental / unproven treatments for patients even if there are few or no alternatives for treatment.  He is hoping to appeal this regulation so that he can continue his research since there is such a high rate of mesothelioma, that disproportionately affects rural Turkish patients.

 The University of Gaziantep Hospital

The University of Gaziantep Hospital

The University Hospital is one of several hospitals in Gaziantep.  The academic institution has over 900 beds and 20 operating rooms spread out over three floors.  There is a large 24 bed surgical ICU which includes 4 dedicated thoracic surgery beds.

Thoracic surgery may not be the advertised superstar of the hospital but it is the backbone of patient care.  There are three full-time professors of surgery; Dr. Ahmet Isik, Dr. Levent Elbeyli and Dr. Bulent Tunçözgür, along with an associate professor, Dr. Maruf Sanli, several thoracic surgery fellows and research assistants.  Together the thoracic surgery team performs over 1000 cases a year.

Dr. Levent Elbeyli is the driving force for thoracic surgery.  A Gaziantep native, he founded the department in 1992, and has seen it grow from a few scattered beds to a full-fledged program with a full-time clinic, 2 dedicated operating rooms, 4 ICU beds and 15 to 20 cases a week.

Dr. Levent Elbeyli (in loupes) in the operating room
Dr. Levent Elbeyli (in loupes) in the operating room

For the thoracic nurse, the department of Thoracic Surgery is a dream come true; tracheal cases, surgical resections, esophagectomies, thoracic trauma – all of the bread and butter that makes our hearts go pitter-pat.  But then there is also plenty of pediatric cases, pectus repair, foreign body removal (oro-esophageal) and on-going surgical research.  They do a large amount of pediatric and infant bronchoscopies (for foreign body obstructions, tracheal malformations etc).

There is the slightly exotic hydatid cysts and the more mundane (but my personal favorite) empyema thoracis to be treated.  Cancers to be staged, and chest wall resections to undertake.  I feel almost overwhelmed in my own petite version of a candy store; everywhere I turn I see opportunities to learn, case reports to write and new things to see.

Dr. Levent Elbeyli operates as Dr. Isik observes.
Dr. Levent Elbeyli operates as Dr. Isik observes.

My non-medical readers might be slightly repulsed by my glee – but it is this intellectual interest that keeps me captivated, engaged and enamored with thoracic surgery and caring for thoracic surgery patients.   And then there is the HITHOC program.  With a large volume of mesothelioma and pleural based cancers due to endemic environmental asbestos in rural regions of Turkey, there is an opportunity to bring hope and alleviate suffering on a larger level.  (Dr. Isik sees more cases here in his clinic in one year than I have seen in my entire career).

What’s not to love about that?

Article updates:

Since our original visit to Dr. Isik, he has continued his work on HITHOC for malignant pleural mesothelioma and other cancers.  You can read his latest paper, “Can hyperthermic intrathoracic perfusion chemotherapy added to lung sparing surgery be the solution for malignant pleural mesothelioma?

In this study, Dr. Isik and hs team looked at 73 patients with malignant pleural mesothelioma (MPM) who were in three different treatment groups.  Group 1 received surgery only (extrapleural pneumonectomy).  Group 2 received palliative treatment only.  Group 3 received lung sparing surgery with hyperthermic chemotherapy (HITHOC).  Lung sparing surgery included pleural decortication.

While the treatment groups are small, the results show a clear survival benefit to the patients receiving HITHOC.   Surprisingly, the palliative group lived longer than the surgery alone group.

Survival based on treatment modality:

Surgery only:  5 months average surgery.  15% survival at 2 years

Palliative treatment only: 6 months average survival   17.6% at 2 years

HITHOC group:  27 months average survival    56.5% at 2 years

Selected Bibliography for Dr. Işık  

Işık AF, Sanlı M, Yılmaz M, Meteroğlu F, Dikensoy O, Sevinç A, Camcı C, Tunçözgür B, Elbeyli L (2013). Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies. Respir Med. 2013 May;107(5):762-7. doi: 10.1016/j.rmed.2013.01.010. Epub 2013 Feb 23. The article that brought me to Turkey, and part of our series of articles on the evolving research behind HITHOC.

Isik AF, Tuncozgur B, Elbeyli L, Akar E. (2007).  Congenital chest wall deformities: a modified surgical technique.  Acta Chir Belg. 2007 Jun;107(3):313-6.

Isik AF, Ozturk G, Ugras S, Karaayvaz M. (2005).  Enzymatic dissection for palliative treatment of esophageal carcinoma: an experimental study.  Interact Cardiovasc Thorac Surg. 2005 Apr;4(2):140-2. Epub 2005 Feb 16.

Er M, Işik AF, Kurnaz M, Cobanoğlu U, Sağay S, Yalçinkaya I. (2003).  Clinical results of four hundred and twenty-four cases with chest trauma. Ulus Travma Acil Cerrahi Derg. 2003 Oct;9(4):267-74. Turkish.

Sanli M, Arslan E, Isik AF, Tuncozgur B, Elbeyli L. (2013). Carinal sleeve pneumonectomy for lung cancer. Acta Chir Belg. 2013 Jul-Aug;113(4):258-62.

Maruf Şanlı, MD, Ahmet Feridun Isik, MD, Sabri Zincirkeser, MD, Osman Elbek, MD, Ahmet Mete, MD, Bulent Tuncozgur, MD and Levent Elbeyli, MD (2008). Reliability of positron emission tomography–computed tomography in identification of mediastinal lymph node status in patients with non–small cell lung cancer. The Journal of Thoracic and Cardiovascular Surgery, Volume 138, Issue 5, Pages 1200–1205, November 2009.

Sanlı M, Isik AF, Tuncozgur B, Elbeyli L. (2009).  A new method in thoracoscopic inferior mediastinal lymph node biopsy: a case report.  J Med Case Rep. 2009 Nov 3;3:96. doi: 10.1186/1752-1947-3-96.

Sanli M, Isik AF, Zincirkeser S, Elbek O, Mete A, Tuncozgur B, Elbeyli L. (2009).  The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma. J Thorac Cardiovasc Surg. 2009 Nov;138(5):1200-5. doi: 10.1016/j.jtcvs.2009.03.035. Epub 2009 Jun 18.

Sanli M, Işik AF, Tunçözgür B, Arslan E, Elbeyli L. (2009).  Resection via median sternotomy in patients with lung cancer invading the main pulmonary artery.  Acta Chir Belg. 2009 Jul-Aug;109(4):484-8.

Sanli M, Isik AF, Tuncozgur B, Elbeyli L.  (2010).  Successful repair in a child with traumatic complex bronchial rupture.  Pediatr Int. 2010 Feb;52(1):e26-8. doi: 10.1111/j.1442-200X.2009.03000.x

Sanli M, Işik AF, Tunçözgür B, Meteroğlu F, Elbeyli L. (2009).  Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture].  Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):71-6. Turkish.

Controlling prolonged air leak by remote control

Dr. Gaetano Rocco talks about persistent air leaks and the development of a remote-controlled computer assisted suction device.

An air leak lasting longer than 5 to 7 days is considered a ‘prolonged or persistent air leak*’.

A prolonged air leak is one of the most frustrating complications after thoracic surgery for patients and clinicians alike.  Far from being life- threatening, a prolonged air leak often occurs in patients that are otherwise stable, healing well and potentially ready for discharge.  However, the presence of a persistent air leak can change all that – by limiting patient mobility and prolonging their hospital stay.

Surgeons have attempted to manage this problem in multiple ways in the past; including additional surgery, application of intra-operative glues and other sealants, repeated post-operative pleurodesis and the implantation of long-term devices like the Heimlich valve (to evacuate air while the lung heals).

More radical therapies such as radiation and endobronchial valves (EBV) have also been used with varying degrees of success (Erdoğan Çetinkaya, M. Akif Özgül, Şule Gül, Ertan Çam, Yakup Büyükpolat, 2012).

Ambulatory suction

In this study, Rocco designed a device capable of providing differing levels of suction independent of wall mounted suction**.  This in itself, is an important feat since being reliant on wall-mounted suction significantly limits the mobility and activity of otherwise ambulatory patients.

In standard cases, patients are essentially tethered to the suction mount in their rooms by a short length of suction tubing. This prolongs hospitalization and can contribute to the development of additional complications.

The Heimlich valve is often used in these cases to allow patients to be discharged home, despite a persistent air leak.  However, while the Heimlich valve relieves patients of this reliance on wall suction, this is also one of it’s limitations.  Independent of wall suction, the Heimlich valve prevents the entry of additional air into the pleural space but can not provide active suction to assist in lung healing.

Prior portable suction technologies

In my experience, our hospital had several antiquated portable suction units that allowed for limited ambulation.  These units were electric-powered suction units that could be wheeled alongside the patient (similar to wheeled oxygen units.)  But these units (dating from the 1950’s – 1960’s and which were found & rehabilitated from an old equipment room) still required the patient to remain in contact with a grounded electrical outlet, though the cord was lengthy.  They were used in limited circumstances in the intensive care and step-down units.

Portable suction unit used at Danville Regional Medical Center, Danville, Virginia.  Photo by Brian Compton
Portable suction unit used at Danville Regional Medical Center, Danville, Virginia. Photo by Brian Compton

Dr. Rocco’s device is a significant upgrade from the 1950’s version, and contains computer sensors to detect, and change the level of suction as needed.  It also contains a chargeable battery that allows patients to function independent of an electrical outlet for up to 48 hours.  This offers considerable freedom, and even permits home use in stable patients.

Continuous patient monitoring

With a laptop computer, both the surgeon and the patient can keep in contact, and monitor progress.  The surgeon can also adjust the amount of suction and review the continuously recorded air leak data.

In this case report, Rocco and his colleagues trialed the equipment  on a patient with a persistent air leak after a right upper lobectomy with wedge resection of the right lower lobe.  The patient was treated and monitored with this device during a stay in the step-down unit, the thoracic floor and finally, in an outpatient setting at a nearby guest house.

While this is a preliminary trial involving a single patient, the potential uses of these technology are considerable – given the frequency of prolonged air leaks post-operatively.  This is also important to consider as minimally invasive surgeries make it possible for patients to be medically stable and otherwise eligible for discharge earlier in the post-operative course.  Given the inherent risks (and costs) of prolonged hospitalization – this may become a viable option a part of a comprehensive discharge plan for many patients who would otherwise remain tethered to a suction mount in a hospital room.

Remote controlled suction -powerpoint slides from Annals of Thoracic Surgery article

* Seven days is the traditional time period but several authors have proposed this be shortened to five days.

** With assistance from Redax corporation.

Reference article

Rocco, G. (2013).  Remote-Controlled, Wireless Chest Drainage System: An Experimental Clinical Setting.  The Annals of Thoracic Surgery – January 2013 (Vol. 95, Issue 1, Pages 319-322, DOI: 10.1016/j.athoracsur.2012.09.079).   Requires subscription.

My apologies to readers – this article was actually published in January of this year, but was somehow overlooked until working on a separate study by Dr. Gaetano Rocco at the National Cancer Institute in Naples, Italy.

Additional References/ Reading

About/ Care of patients with Heimlich Valves – KPJ Ampang Puteri Specialty Hospital, Malaysia

Dimos Karangelis, Georgios I Tagarakis, Marios Daskalopoulos, Georgios Skoumis, Nicholaos Desimonas, Vasileios Saleptsis, Theocharis Koufakis, Athanasios Drakos, Dimitrios Papadopoulos, Nikolaos B Tsilimingas (2010).  Intrapleural instillation of autologous blood for persistent air leak in spontaneous pneumothorax- is it as effective as it is safe?  J Cardiothorac Surg. 2010; 5: 61. Published online 2010 August 17. doi: 10.1186/1749-8090-5-61.  The authors investigate the use of blood pleurodesis in fifteen patients and report a 27% success rate.

Erdoğan Çetinkaya, M. Akif Özgül, Şule Gül, Ertan Çam, Yakup Büyükpolat (2012).  Treatment of a Prolonged Air Leak with Radiotherapy: A Case Report.  Case Rep Pulmonol. 2012; 2012: 158371. Published online 2012 September 27. doi: 10.1155/2012/158371.  In this case report, surgeons in Istanbul, Turkey, radiation was applied to a localized area after the probably area of air leak was identified thru ventilation scintigraphy.  Patient received two doses of 10 G to a 10 X 10 cm area with resolution of air leak.

Cosimo Lequaglie, Gabriella Giudice, Rita Marasco, Aniello Della Morte, Massimiliano Gallo (2012).  Use of a sealant to prevent prolonged air leaks after lung resection: a prospective randomized study.  J Cardiothorac Surg. 2012; 7: 106. Published online 2012 October 8. doi: 10.1186/1749-8090-7-106.

Rathinam S, Steyn RS (2007). Management of complicated postoperative air-leak – a new indication for the Asherman chest seal. Interact Cardiovasc Thorac Surg. 2007 Dec;6(6):691-4. Epub 2007 Sep 11. Using a heimlich valve for persistent air leaks.

Tudor P Toma, Onn Min Kon, William Oldfield, Reina Sanefuji, Mark Griffiths, Frank Wells, Siva Sivasothy, Michael Dusmet, Duncan M Geddes, Michael I Polkey (2007).  Reduction of persistent air leak with endoscopic valve implants.  Thorax. 2007 September; 62(9): 830–833. doi: 10.1136/thx.2005.044537  Discussion of endobronchial valves (EBV).

mystery diagnosis: pleural plaques

Discovery of extensive pleural plaques during VATS

Usually with pleural plaques, you think of two possible diagnoses: metastatic cancer and tuberculosis.

But which is the more likely culprit?*  That kind of depends on both your patient and your geographic location.

If this had been in my native Virginia – I’d “assume/ guess” metastatic cancer  (since my patient population is usually older, high rate of smoking, other risk factors for cancer).

But luckily (who ever thought I’d be saying luckily) in my current location (Northern Mexico) in this patient (with multiple risk factors for infectious disease but no asbestos exposure) – tuberculosis is the more likely diagnosis.

* Prior to formal tissue pathology results, which confirmed tuberculosis in this patient.

** I apologize for the lack of formal references, but I was unable to find any comprehensive literature (available as free articles).

Radiology Reference on-line article

Congreso Nacional: Wednesday Highlights

continued coverage of the2012 (Mexican) National Conference in Cancun, Mexico with discussions by Dr. Rafael Andrade, Dr. Raimundo Santolaya and Dr. Enrique Guzman de Alba.

LXXI Congreso Nacional de Neumologia y Cirugia de Torax

Cancun, Mexico

Yesterday was such a flurry of activity – I didn’t get a chance to post Wednesday’s Conference highlights until now.

After sitting thru some lackluster presentations for most of Tuesday, today was definitely the best day of the conference so far; as the topics become more and more thoracic surgery related (versus Asthma, and other strictly pulmonary medicine topics).  There were so many enjoyable and informative lectures today that is was hard to choose, even after deciding to pick more than one – I feel like apologizing to all the other great speakers – but I’ve narrowed it down to a trifecta of great speakers, with Dr. Raimundo SantolayaDr. Rafael Andrade, and Dr. Enrique Guzman de Alba.

Dr. Ramundi Santolaya, MD a Chilean thoracic surgeon gave a thoroughly enjoyable overview of the diagnosis and management of pneumothoraces.  Whether it was due to innate charisma, a lively discussion and multi-media presentation on one of my favorite topics, or due to that fact that with his clear, unaccented Spanish – I didn’t miss a word – he was a standout star of the day – so much so that I chased him down later for a full interview.

Dr. Raimundo Santolaya, of Santiago, Chile discusses 'Actualidades en el manejo del neumotorax'

Dr.  Rafael Andrade, from the University of Minnesota was also very informative, yet entertaining during his talk on the use of ultrasound for mediastinal evaluation  (cancer staging).   He explained that while mediastinoscopy remains the gold standard for staging lung cancer, that the new(er) ultrasound techniques including endobronchial (EBUS) and endoesophageal (EUS) ultrasound allow for tissue sampling (and biopsy) of lymph nodes that are normally inaccessible during mediastinoscopy including many of the more distal stations.  These techniques do not replace mediastinoscopy, or mediastinotomy (Chamberlain) but offer complimentary information to assist in the staging of cancers to help determine the extent of disease when PET results may be inconclusive, or appear to show more extensive disease.

I had just finished reading some of his recent papers for another article I was working on, so it was both a surprise and a pleasure to see him and speak with him, in person.  He sure didn’t seem to mind my questions (despite my chronically impaired Spanish.)

Dr. Rafael Andrade takes the time to speak with Cirugiadetorax.org

Of course, his English is impeccable but when in Rome, etc. so I did my best.  Luckily for me, and all the readers here at Cirugia de Torax – my understanding of ‘surgical Spanish’ tends to be spot – on, particularly when there are overhead slides to assist with translation.

Dr. Rafael Andrade, University of Minnesota presents, 'Valor del ultrasonido toracico en las enfermedades pleurales

Dr. Enrique Guzman de Alba, a cardiothoracic surgeon gave two lectures, more of a part I and a part II on the current literature regarding the surgical treatment of lung cancers by staging as well as a review of the literature surrounding clinical outcomes comparing lobectomy versus segmentectomy (aka wedge resections.)  As he explained, lobectomy remains the gold standard for any patient who is able to tolerate surgery, (including patients that are believed to be marginal candidates and would otherwise be relegated to wedge resection.)  He reports that despite common beliefs regarding segmentectomies as ‘lung -sparing’ for patients with marginal baseline respiratory (or other functional) status – there has been no data to demonstrate that these patients perform better/ or better tolerate a wedge resection versus the more complete lobectomy.  Therefore, given the increased incidence of cancer reoccurrence with segmentectomies – he advocates for the larger, but more effective lobectomy.

Dr. Enrique Guzman de Alba, cardiothoracic surgeon at INER, Mexico City, Mexico giving one of several presentations

There was also some interesting discussion on managing malignant pleural effusions and limitations of PleurX catheter use in Mexico due to prohibitive costs for many patients.

Pulmonology throws down the gauntlet..

Evaluation and discussion of a new article by Davies et. al. (2011) which calls many of the current practices in thoracic surgery into question. Is this a legitimate assessment of evolving treatment strategies or another attempt for pulmonology to encroach on the thoracic surgery specialty? In this multi-part series, we will address the major points debated in this article.

In a recent article by several pulmonologists in Australia (Helen E. Davies, Andrew Rosenstengel and Y.C. Gary Lee) the authors contend the recent developments in pulmonology have largely made the thoracic surgery specialty obsolete – particularly in the treatment of pleural disease. Are there merits to their claims?  or is this just another example of an expanding turf war, reminiscent of recent battles between cardiology and cardiac surgery?

We will re-post the article here, and discuss their findings at length in a multi-part series.

From Current Opinion in Pulmonary Medicine, “The Diminishing Role of Surgery in Pleural Disease”

Helen E. Davies; Andrew Rosenstengel; Y.C. Gary Lee

 Curr Opin Pulm Med. 2011;17(4):247-254.

Abstract and Introduction


Purpose of review Pleural disease is common. Traditionally, many patients were subjected to surgery for diagnosis and treatment. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal and their use is based on anecdotal series with selection bias. The evidence (or the lack) of benefits of surgery in common pleural conditions is reviewed.
Recent findings Recent studies do not support the routine therapeutic use of surgery in patients with malignant pleural effusions, empyema or mesothelioma. Four randomized studies have failed to show significant benefits of thoracoscopic poudrage over bedside pleurodesis. Surgery as first-line therapy for empyema was studied in four randomized studies with mixed results and no consistent benefits. Cumulative evidence suggests that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified. Advances in imaging modalities and histopathological tools have minimized the need for surgery in the workup of pleural effusions. Complications associated with surgery are increasingly recognized.
Summary Surgery has associated perioperative risks and costs, and residual pain is not uncommon. Many conventional pleural surgeries have not been assessed in randomized studies. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make informed clinical decisions and optimize patient care.


Pleural diseases are common; over 1 500 000 patients develop a new pleural effusion annually in the USA alone.[1] Pleural effusion can arise from more than 60 causes, and establishing the cause and effective treatment can be challenging.

Thoracic surgery traditionally plays a major role in the workup and management of pleural effusions, from pleural biopsies to pleurodesis and from empyema to pneumothorax. Various aggressive pleural surgeries have been developed over the years: from the description of Clagett procedure in 1963[2] – a three-stage radical procedure with chest wall resection to create a permanent open window for pleural empyema – to modern day extrapleural pneumonectomy (EPP) for mesothelioma, which involves resection of lung, chest wall, hemidiaphragm, pericardium and regional lymph nodes. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal (let alone randomized studies) and their use is based largely on anecdotal series often flawed with selection bias.

The aim of management of pleural diseases is to deliver the diagnosis and best management with the least invasive procedure(s), shortest hospitalization period and lowest procedural morbidity and cost. Realization of the lack of evidence for many pleural surgeries, and the growing documentation of their procedure-related complications, has prompted the pleural community to examine ‘conventionally accepted’ pleural surgical approaches using randomized trials. Not surprisingly, many (e.g. thoracoscopic poudrage) have failed to demonstrate any significant benefits. Advances in imaging techniques, histopathology methods and therapeutic protocols further contribute to a reduction in need for invasive surgeries. Worldwide, in recent decades, the role of surgical intervention for the diagnosis and management of pleural disease has diminished significantly.

Clinicians must be critically aware of the evidence (or lack of evidence) supporting a specific surgical intervention before subjecting their patient to an operation. Progress can only be made if clinicians continue to challenge the truthfulness of ‘conventional wisdom’ and work toward less invasive means to achieve better patient care.

In this review, we discuss the role of surgery in commonly encountered pleural diseases and highlight the deficit in evidence that supports many ‘accepted’ surgical interventions, and the advances in pleural research which suggest parity or superiority of noninvasive approaches.

Surgery for Diagnosis of Pleural Effusions

A significant shift in the choice of diagnostic procedure for undiagnosed pleural effusion has been seen in recent years. Open thoracotomy, once the gold standard, has given way to less invasive video-assisted thoracoscopic surgery (VATS). In turn, VATS is giving way to the less invasive pleuroscopy (or medical thoracoscopy). VATS requires general anesthesia and is performed usually through two to four portals of entry. Pleuroscopy is performed usually by pulmonologists under conscious sedation with a single or double port of entry, often as a day case.

In the UK, the number of centers offering pleuroscopy has jumped from 11 to 37 in the past decade, significantly reducing the need for VATS or open pleural biopsies.[3] Flexi-rigid pleuroscopy further increases the ease of the procedure over traditional rigid thoracoscopy and is gaining popularity.

This march toward less invasive procedures is in part driven by the realization that surgery carries a risk of chronic complications. Furrer et al.[4] reported that chronic intercostal neuralgia (persistent pain) occurred in up to 44% of patients at 6 months postthoracotomy. In another series (n = 56), 9% of patients suffered from chronic postthoracotomy pain severe enough to require daily analgesia, nerve blocks, acupuncture or specialist pain clinic visits.[5] It is not surprising that a systematic review favored VATS over thoracotomy, reporting lower analgesia requirements and a shorter length of hospital stay. However, VATS is still associated with persistent pain or discomfort at the operation site in over a third of patients after 3–18 months.[4]

No studies directly compare VATS with pleuroscopy, but several large case series have suggested similar diagnostic efficacy for malignancy. Pooled results from case series evaluating pleuroscopy show a diagnostic sensitivity for malignant pleural disease of 92.6% (95% confidence interval 91.0%–93.9%),[6–25] comparable to those achieved following VATS pleural biopsy.[26,27] Pleuroscopy is a well-tolerated, cost-effective procedure. Mortality rates are low (<0.01%) and, in a series of over 6000 cases, surgical intervention was never required for hemostasis.[28] Pleuroscopy is preferable over VATS if initial fluid analyses were uninformative, especially in suspected cases of malignant or tuberculous pleural effusions.

Furthermore, technological improvements in diagnostic imaging modalities have reduced the need for thoracoscopic biopsies. Computed tomography with pleural phase enhancement provides closer definition of the pleural surfaces and circumferential, nodular or mediastinal thickening, and a parietal pleural thickness of more than 1 cm provides diagnostic specificities of 100%, 94%, 88% and 94%, respectively, for malignant disease.[29] Similar results were recently demonstrated by Qureshi et al.[30] using pleural ultrasound.

In patients with radiological evidence of pleural thickening, the diagnostic sensitivity of imaging-guided and thoracoscopically obtained pleural biopsy samples is comparable (approaching 90%).[3]

Advances in laboratory tests and biomarkers for pleural diseases also significantly reduce the need for pleural tissue biopsies. In many endemic countries, adenosine deaminase is used in the diagnosis of tuberculous effusion especially in patients with a compatible clinical picture and a lymphocyte-predominant effusion, negating thoracoscopic biopsies.[27,31] Other examples include flow cytometry for diagnosing lymphoma from pleural fluids, amylase for pancreatic effusions or ruptured esophagus and beta-2 transferrin for duropleural fistulae.

In patients with suspected mesothelioma, the use of a rapidly growing number of biomarkers has been proposed to aid the diagnosis through serum or pleural fluid analyses (reviewed elsewhere[32,33]). Although none can substitute a histocytological diagnosis, a high mesothelin level in cases with suspicious cytology of mesothelioma can add confidence to diagnostic certainty and may obviate the need for surgery.[34] In a study of 167 prospective patients presenting with undiagnosed pleural effusion, a negative mesothelin level together with negative pleural fluid cytology for malignancy yield a negative predictive value of 94%[34] – highly comparable to the false negative rate for pleuroscopy in three large series.[13,35,36] It is anticipated that within the next decade, these biomarkers will have an established place in the diagnostic algorithms for common pleural conditions, further minimizing the need for thoracoscopy.

Surgery for Pleural Infection

Pleural infection is a centuries’ old problem, but its incidence continues to rise despite better medical care and antimicrobials. The principle of therapy is control of sepsis (antibiotics) and drainage of the infected pleural fluid collection by thoracentesis, and if this fails, surgical evacuation.

Empyema is still considered in many centers as a ‘surgical’ disease, where surgeons will insert large bore chest tubes and have a low threshold of performing thoracoscopy for fluid evacuation if there are residual radiographic opacities. The conventional belief of the benefits of surgery stemmed from many anecdotal series, flawed by selection bias. The magnitude of that bias has recently been quantified in a retrospective series of 4424 empyema patients in the USA over 20 years.[37] Empyema patients selected for surgery were significantly younger by almost 10 years (52.9 vs. 61.5 years, P < 0.001) and had a significantly lower comorbidity index (0.8 vs. 1.4, P < 0.001).[37] VATS procedures often (up to 17%[38]) require conversion to open thoracotomy, thus increasing postoperative morbidity (see above). Many aspects of these ‘conventional practices’ are now shown to be overaggressive and unnecessary. There are several factors to consider.

First, the majority of patients with pleural infection can be adequately treated with antibiotics and chest tube drainage, without needing surgery. In the Multicentre Intrapleural Sepsis Trial (MIST) (n = 454), only 18% (n = 74) failed the above approach and required surgical treatment.[39•] [This is akin to pneumothorax management, where a 20% recurrence risk after the first episode does not warrant automatic surgery.[40] Routinely, subjecting all empyema patients to surgery is, therefore, unnecessary.

Four randomized clinical trials (RCTs) have now compared first-line VATS with conservative treatment (antibiotics and chest tube drainage with/without fibrinolytics). No major advantage (e.g. on mortality) has been documented with early surgical approach in all the trials. Two RCTs of pediatric empyema, comparing primary VATS intervention with chest drain and intrapleural fibrinolytic, both showed no advantages of early surgery. On the contrary, Sonnappa et al.[41] showed that surgery was more expensive ($11 379 vs. $9127) but did not alter outcome over conservative management in 60 children with pleural infection. Higher hospital charges were observed in the study by St Peter et al.[42] and similarly no significant differences in length of stay, oxygen requirement, days until afebrile or analgesia needed (n = 36). The two trials on adult empyema were small (n = 19 and 70, respectively) and difficult to interpret. Clear criteria to guide the need for surgical decortication, following the initial treatment administered postrandomization, are lacking in both studies.[43,44] Bilgin et al.[43] and Wait et al.[44] both randomized patients for immediate VATS or chest drain and antibiotics +/− intrapleural fibrinolytic. Neither study showed a major benefit other than shorter hospital stays (8.7 vs. 12.8 and 8.3 vs. 12.8 days, respectively). Hence, a recent Cochrane review concluded that further studies are needed to determine best practice.[45]

Supplementing improvements in antimicrobial therapies, imaging guidance of chest tube drainage is now increasingly used in place of surgical evacuation of pleural collections. This practice has reduced the amount of patients subjected to surgery, though the exact magnitude of the reduction is difficult to quantify.

Intrapleural therapy to aid the drainage also can negate the need for surgical evacuation. A large randomized study (n = 454) and subsequent meta-analysis have shown no benefit from intrapleural streptokinase therapy alone.[39•,46] However, the combined intrapleural use of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) to breakdown adhesions and thin pus has synergistic benefits in preclinical models.[47,48] This has led to a factorial trial of intrapleural tPA and DNase in patients with pleural infection. Preliminary results from the MIST-2 study (presented at the British Thoracic Society 2009 scientific meeting[49]) appear promising: tPA and DNase improved radiological clearance of pleural abnormalities and reduced hospital stay. Only 5% of patients treated with this combination required surgical debridement.

Second, surgical decortication postempyema is grossly overemployed. Many centers submit patients to surgical decortication because of residual radiologic changes, even when sepsis had subsided. This practice is not supported by current clinical practice guidelines, which recommend surgery only in patients with persistent sepsis and a residual pleural collection despite appropriate drainage and antimicrobial therapy.[50] Longitudinal follow-up data from large clinical studies showed that residual pleural opacities will resolve with time, as the inflammatory changes settle.[39•,51] This is akin to radiographic parenchymal changes in patients with pneumonia.

Third, conventional teaching advocates large bore chest tube drainage for empyema and, in many centers, large drains are inserted only by thoracic surgeons. Traditionally, the main arguments for large catheters have been a better drainage rate, especially in draining pus, and a lower blockage rate. However, no evidence-based data concur with this supposition.[52•] The difference in drainage rate for pus is not significant once the size of internal diameter of the catheter reaches at least 8F or above (~12–14F external diameter). Rates of drain blockage in empyema, another conventional concern, are similar in published literature between large and small bore drains; and regular flushing of small bore catheters often overcomes the problem of blockage.[53]

Empyema fails to drain most commonly because of multiple septations, a hurdle which large drains will not overcome; increasing numbers of studies now show that larger drain size does not increase efficacy, even in empyema. In their study, analysing data on 405 patients with empyema, Rahman et al.[52•] showed no significant difference in mortality, need for subsequent thoracic surgery, length of hospital stay, lung function or radiographic resolution in patients with chest tubes of varying sizes (<10F, 10–14F, 15–20F or >20F).

The main drawback of the large bore catheters is pain secondary to the larger incision and subcutaneous/transpleural tract required, as reported in several series.[52•,54] Others have shown higher rates of infection with large tubes.[55,56]

Surgery for Malignant Pleural Effusions

As many as 100 000 patients in Europe develop a malignant pleural effusion from lung cancer alone[57] and 150 000 cancer patients in USA have a malignant pleural effusion each year.[58] Little evidence suggests thoracic surgery has a salient therapeutic role in malignant effusion management, even though it is often employed worldwide.

Pleurodesis is considered the best therapy wherever suitable and, in head-on comparisons, talc has been shown to be superior to bleomycin, tetracycline or doxycycline.[59–65] The optimal route for delivery of talc is controversial.

Talc poudrage administered by VATS is traditionally thought to be more effective than bedside slurry instilled via a chest tube. However, talc induces pleural mesothelial damage with subsequent pleural inflammation and symphysis, rather than acting as a glue;[66–69] therefore, the supposed even distribution which results from insufflation is not essential for successful pleurodesis. Radioactive isotope studies have shown that talc can distribute around the pleural cavity by respiratory motions even if administered as slurry.[70]

All randomized trials to date have failed to show a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis; three recent studies have compared talc poudrage with talc slurry,[71•,73,74] and one, by Mohsen et al.,[72] with povidone iodine. These are outlined in Table 1.[71•,72–74]

Table 1. Recent trials comparing talc slurry and bedside chemical pleurodesis

Reference; study design Patient number Primary cancer (TP/TS) Length of follow up Outcome measures Result
Dresler et al. [71•]; TP=251 Lung: 89/93 Until death Recurrence rate at 30 days: No significant difference
RCT TS=250 Breast: 59/56 TP: 145/251 Similar success rates at 30 days (75%) and efficacy at 6 months (50%)
TS: 126/250 (P=NS)
Yim et al. [74]; TP=28 Lung: 18/15 Until death Recurrence rate: No significant difference
RCT TS=29 Breast: 6/9 TP: 1/28
GIT/other: 4/5 TS:3/29
Terra et al. [73]; TP=30 Breast: 15/19 6 months Postpleurodesis lung expansion No significant difference in Clinical outcome complications or quality of life
RCT TC=30 Lung: 11/6 Radiological recurrence
Lymphoma: 2/1 Clinical recurrence (requiring intervention):
Unknown: 1/1 TP: 5/30
Other: 1/3 TS: 4/30
Mohsen et al. [72]; TP=22 All breast 4 years Recurrence requiring intervention: No significant difference
RCT PI=20 TP: 2/22
PI: 3/20

GIT, gastrointestinal; NS, not significant; PI, povidone iodine; RCT, randomized controlled trial; TP, talc poudrage; TS, talc slurry

The largest trial by Dresler et al.[71•] showed that talc poudrage at thoracoscopy induced significantly more complications than talc slurry pleurodesis. Rates of pneumonia requiring antibiotics, respiratory failure, bronchopleural fistulae, requirement for blood transfusion, atelectasis requiring more than two bronchoscopies, dysrhythmia, deep vein thrombosis, pulmonary embolism and postoperative death rates were all increased in the talc poudrage compared with the bedside talc slurry group.[71•] Success rates of both techniques were similar (~75%) at 30 days after procedure. Efficacy reduced with time to approximately 50% at 6 months and a suggestion of a trend toward talc slurry being more effective.[71•]

Indwelling Pleural Catheters

One major recent advance has been the increased utility of indwelling pleural catheters (IPC). These may be inserted as a day-case procedure, with local anesthesia and conscious sedation, thus reducing hospital time and avoiding the risks inherent to a general anaesthetic. It is now the preferred treatment method for patients with an underlying trapped lung and those who fail initial pleurodesis.[75] Extending the use of IPC as a first-line treatment for patients with malignant pleural effusion is the subject of randomized trials in Europe. Recent series suggest that bedside insertion of IPC by pulmonologists or interventional radiologists is as well tolerated as surgical placement in the operating rooms.[76]

Surgery for Malignant Pleural Mesothelioma

Perhaps the most aggressive pleural surgery performed nowadays is EPP. EPP is usually part of trimodality treatment in combination with chemotherapy and hemithoracic radiotherapy. Little high-quality evidence supports its use.

Even in the most experienced centers and despite surgical advances, the perioperative mortality rate remains approximately 4%.[77] Other centers have observed similar findings; e.g. Rice et al.[78] had 8% mortality in 100 cases of EPP; Stewart et al.[79] had 7% mortality in 74 patients and Hasani et al.[80] had 11% mortality in a series of 18 patients. There is also significant associated morbidity: Sugarbaker et al.[77] report a complication rate in excess of 60%, a finding echoed by Schipper et al.[81] (who also report a 3-year survival rate of only 14%). Life-threatening complications affect 25% of patients, including surgical complications requiring re-exploration (7%), cardiac arrest/myocardial infarction (5%), prolonged intubation (8%), deep vein thrombosis and renal failure.[77] Late mortality (days 30–180) is significant, killing as many patients as in the first 30 days in one report. Additional morbidity arises from the chemotherapy and radiotherapy arms of the trimodality regime.

Despite this unacceptable safety profile, the trimodality approach does not cure mesothelioma. Alarmingly, though not surprisingly, Weder et al.[82] reported worsening of quality of life in patients who underwent EPP, especially in physical, psychological and activity scores for at least up to 6 months after surgery. Although improved long-term survival has been claimed, the data are almost certainly a result of selection bias.

The Mesothelioma and Radical Surgery (MARS) trial was designed to address the role of EPP as a component of trimodality treatment in malignant mesothelioma.[83] Even in the 300 patients believed to be potentially suitable and referred, only 50 were ultimately eligible after screening and were randomized; further confirming that EPP, even if useful, is applicable only to a minority of patients and will not make an impact on the global burden of mesothelioma.[84]

Increasing data confirmed that EPP has a worse outcome than less radical surgery, for example pleurectomy/decortication. Flores et al.[85] showed in a large but nonrandomized series that patients who underwent pleurectomy had improved survival compared with those who underwent EPP. Nakas et al.[86] reported significant improvements in pain and dyspnea with VATS pleurectomy/decortication (n = 67) compared with EPP (n = 112), with improved 30 day mortality (VATS group 7.1% vs. EPP 23%), reduced hospital stay (14.3 days vs. 36.6 days) and overall mean survival (14.0 months vs. 11.5 months) in patients aged more than 65 years.

The most striking data to show the lack of surgical benefits came from Flores et al.,[87] who in a large retrospective series showed a median survival of 14.3 months in patients undergoing EPP (n = 208) compared with 15.8 months (n = 176) following pleurectomy/decortication. Both were only marginally better than the median survival for patients (n = 174) who underwent explorative thoracotomy and were found to have extensive and inoperable disease (12.7 months).

Mesothelioma is not a solitary tumor but spreads along serosal surfaces. Surgery is not likely therefore to provide cure, as has been the observation to date. Because of the lag time between exposure and disease onset, the patients are often elderly with significant comorbidity, and current data do not support aggressive operations.

Surgery for Chylothorax

Although dietary manipulation may reduce chyle flow, patients with refractory chylothoraces often require surgical ligation of the thoracic duct if this fails, necessitating either VATS or thoracotomy. Increasing reports suggest that percutaneous thoracic duct embolization using fluoroscopic guidance may be effective and can obviate the need for invasive surgery.[88,89]

Surgery for Pneumothorax

The majority of pneumothoraces can be managed without surgery. Patients with small primary spontaneous pneumothoraces (PSP) or with no symptoms, regardless of the size of the pneumothorax, may be safely treated with observation alone. Guidelines recommend initial pleural aspiration for patients with PSP and significant symptoms, and that any patient with a secondary spontaneous pneumothorax (SSP) has an intercostal chest drain inserted.[41]

No evidence exists on which to base timing of referral for surgical intervention in patients with an ongoing air leak. International guidelines recommend that an opinion is sought within 2–5 days; however, this timeline is largely arbitrary.[41,90]

Several retrospective studies argue against early surgical treatment. One retrospective review (n = 115) reported spontaneous resolution rates of 74% and 100% for those with PSP at 7 and 15 days, respectively; and 61% and 79% (at 7 and 14 days, respectively) for patients with SSP. Only five patients required surgical intervention.[91] Two further studies of PSP showed that only 37% had an air leak at presentation, resolving in two thirds of cases within 1 week without intervention.

Ferraro et al.[92] compared conservative (including tube thoracostomy) to surgical intervention (apical resection with either pleurectomy of pleural abrasion) for 366 patients with 508 episodes of spontaneous pneumothorax (239 patients with PSP, 127 with SSP). No significant difference was noted between the two groups in terms of recurrence rates.

Other nonsurgical approaches under exploration include ambulatory management with chest tube and one-way valve, and pleuroscopy. For patients with SSP, who are more likely to have a prolonged air leak and less likely to tolerate surgical intervention, prolonged observation, intercostal catheter drainage and use of flutter valves may preclude the need for surgery. Medical thoracoscopy as an alternative to VATS has increasingly been used for the management of spontaneous pneumothorax. Tschopp et al.[93] in a RCT compared the efficacy of VATS pleurodesis (via abrasion or talc poudrage) to poudrage via medical thoracoscopy, showing no difference in long-term recurrence rate (approximately 5%).


For centuries, different surgical procedures have been used for various pleural diseases, without any quality data to prove their benefits over conservative alternatives. Surgery has associated perioperative risks and costs; and residual pain is not uncommon. To date, the randomized studies on surgical approaches have not shown a significant advantage in the settings of pleural infection, malignant effusions and mesothelioma. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make well-informed clinical decisions and optimize patient care.


Key Points

  • The overall aim of medical practice is to diagnose and treat with the least invasive methods.
  • There is a paucity of randomized evidence to support surgical intervention for many pleural diseases and physicians need to be aware of this in order to make well-informed clinical decisions to optimize patient care.
  • Radical surgery, especially extrapleural pneumonectomy, is not justified for patients with mesothelioma.
  • Advances in pleural research suggest parity or improved outcomes with less interventional approaches for patients with empyema.


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    • of special interest
    •• of outstanding interest
    Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 293).

Professor Y.C.G.L. receives research grants from the Western Australian Health Department (State Health Research Advisory Council), Sir Charles Gairdner Research Funds, Raine Medical Research Foundation and the Cancer Council of Western Australia.

Curr Opin Pulm Med. 2011;17(4):247-254. © 2011 Lippincott Williams & Wilkins

We’ll be talking about each of these concepts/ treatments in turn in future posts with related research, and published literature.  However, it is immediately apparent in reviewing this work that the authors selectively chose their references to reflect their pre-existing viewpoints – and that much of data on which their conclusions are based is considerable outdated.  While we respectfully appreciate the historical perspectives inherent in thoracic surgery – this type of ‘data culling’ is a deceptive practice.

Cytoreductive Surgery with Intraoperative Hyperthermic Intrathoracic Chemotherapy

An introduction to cytoreductive surgery with hyperthermic intrathoracic chemotherapy administrative for the treatment of malignant pleural mesothelioma.

Cytoreductive surgery with Intraoperative Hyperthermic Chemotherapy (HIPEC) has been used for over a decade now for abdominal cancers including metastatic colon cancer (peritoneal carcinomatosis) and malignant peritoneal mesothelioma.  During this lengthy procedure, surgeons remove as much gross disease as possible, and then infuse heated chemotherapy agents directly into the abdominal cavity to kill any residual cancer cells.  One of the benefits of this treatment is that by directly administering chemotherapy to the site of disease – the patient experiences less toxic side effects (versus intravenous or oral ingestion) and higher concentrations can be used, which are more effective at killing the malignant cells.  Research findings have been encouraging, and have shown significant improvement in median survival in comparison to standard treatment.

During my research in Bogotá, Colombia – I interviewed a general surgeon who was responsible for establishing a HIPEC treatment program in a local hospital there.  (There are less than 25 HIPEC treatment centers in the world.)  This spurred my interest in thoracic applications of this procedure (called the Sugarbaker procedure after the inventor, Dr. Paul Sugarbaker, an oncologist.)

In recent years, thoracic surgery has investigated and adopted some of this research for use and treatment of thoracic cancers, in a procedure known as HITHOC.  In thoracic surgery, intrathoracic (inside the chest) administration of heated chemotherapy in the operating room has been used primarily to treat malignant thymomas and malignant pleural mesothelioma.  Results of recent studies have been mixed – with the best results occurring in patients with thymomas.  In patients with mesothelioma, prognosis is dependent on stage.

Rutgers and Bree et. al at the Netherlands Cancer Institute published several additional studies on the subject,  looking at the effectiveness of different chemotherapeutic agents for HITHOC.  Given their extensive experience and knowledge on the subject, I have contacted the researchers at the Netherlands Cancer Institute to invite the authors to submit a guest post.  (I’d rather all of you hear from the experts!)

Additional References: (links when possible)

1. Dutch study using the Sugarbaker procedure for intrathoracic infusion for pleural thymomas and malignant pleural mesothelioma.  Bree et. al (2000) from Chest. Small study with only 14 patients but a nice discussion of the procedure with graphics. Multiple other studies from these authors, as mentioned above.

2. A nice blog that explains the Sugarbaker procedure.

3. Very small Japanese study from 2003 – five patients.  Notably, these patients had a different disease process – lung cancer with pleuritic carcinomatosis. 4 out of five patients demonstrated significant longevity after the procedure with no recurrence.