A glimpse into the role of debulking surgery and hyperthermic intrathoracic chemotherapy (HITHOC) in the management of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a devastating malignant disease with a poor prognosis due to the lack of effective treatment and the advanced stage evidenced at diagnosis. Multimodality treatment involving chemotherapy, surgery, and radiotherapy is currently the advised regimen to prolong survival. Recently, surgeons and oncologist increased their interest in new innovative treatments such as hyperthermic intrathoracic chemotherapy (HITHOC) and immunotherapy. The role played by surgery appears questionable due to the unattainability of radical resection in most cases and is based on the performance of different surgical techniques to achieve cytoreductive surgery ranging from aggressive extrapleural pneumonectomy to pleurectomy/decortication. HITHOC was introduced several decades ago where the anti-tumoral effects of chemotherapy work synergistically alongside the cytotoxic effect of high temperature on exposed tissue, hence, aiming to improve surgical radicalism. However, its role in the treatment of MPM is still controversial. Hereby, we present a literature review of the role of HITHOC following cytoreductive surgery in the management of patients with MPM. In most cases, an excellent local control was obtained as well as a better overall survival associated with a low rate of complication. HITHOC may be considered a feasible, safe, and highly effective procedure even though there is a high heterogeneity between the protocols adopted globally. There is a need for further structured research to arrive at a unanimous consensus on this technique.