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lacunae.2 Pleural dissemination represents advanced palliative disease, with limited treatment options. There has been some success with iso- lated case reports using hyperthermic intrathoracic chemotherapy (HITHOC),3 but the operative technique has not been described. We herein describe our HITHOC technique on a 50-year-old woman who was referred from our local peritonectomy unit with pleural PMP dis- ease following ve prior CRS and four prior HIPEC procedures (Fig. 1a). Unfortunately, her disease was deemed to be resistant to mitomycin C which is the usual chemotherapeutic agent of choice in PMP.4 After much deliberation with the peritonectomy unit, it was felt that oxaliplatin should be used to minimise the risk of recurrence, despite this drug being a second-line treatment for peritoneal PMP and not previously described in HITHOC. Given the lower rate of systemic absorption in HITHOC compared with HIPEC, it was felt safe to use the standard dosage calculation of 300 mg/m2.4
The operation is performed with the guidance of the per- itonectomy unit, utilising a theatre team, anaesthetists and perfu- sionists who are experienced in HIPEC procedures. The patient is positioned in a lateral decubitus position using a sandbag (Fig. 1b). Exposure is maximised by breaking the table under the costal mar- gin and adding an axillary roll. A lateral thoracotomy is undertaken in the sixth intercostal space, extending from the mid- to posterior axillary line. Adhesions are cleared and mucinous lesions are excised under thoracoscopic or direct vision. Once adequate re- section of all gross disease has been achieved, a medium Alexis (Applied Medical, CA, USA) is inserted into the thoracotomy wound. Two separate incisions are placed in the seventh intercostal space with two 28 Fr intercostal catheters: the inow catheter is placed apically, and the outow catheter is placed at a lower level in the paravertebral recess. The thoracotomy is then sealed with three layers of Ioban dressings (3M, Minnesota, USA). A small incision is made for a separate suction drainage to evacuate cyto- toxic fumes and sealed with dressings. A small opening is made through the Ioban to ensure that the suction remains open to air, only evacuating fumes and not the chemotherapeutic agents. This opening can also be partially covered with a gauze dressing to mini- mise the proceduralist exposure. The catheters are connected via 3/8 inlet lines to the HITHOC circuit, which consists of a roller pump, reservoir and heat exchanger; a second pump is available in case extra drain catheters are needed (Fig. 1c). The system is primed with 1800 ml of Dianeal uid5 and circulated to maintain a circulating temperature of 4143 C. Oxaliplatin (495 mg; dosage 300 mg/m2, half-life of 14 min) is added to the priming uid. The hemithorax is then lled with perfusate to fully cover the base of the thoracotomy wound, and circulated at 850 ml/min for 30 min with nasopharyngeal and pump line temperature monitoring. On completion, the thoracic cavity is irrigated with 1.5 L of Dianeal uid.
Once the HITHOC has been administered, all cytotoxic waste is disposed of, including the inow and outow lines, suction tubing and supercial Ioban dressings. The 28-Fr drains are left in situ and function as pleural drains. The thoracotomy is closed in a stan- dard fashion. Post-operatively, the drains are connected to a three- chamber underwater seal drain on suction for 48 h. The patient is

transferred to the intensive care unit ICU with cytotoxic precautions for 48 h. Resected lesions are sent for histopathology. In this case, the patient was discharged at 7 days post-operatively without com- plication. Follow-up imaging at 3 months showed no evidence of recurrence. This procedure, as with HIPEC, may be repeated as required to control disease recurrence.
This is the rst description of operative technique of HITHOC for PMP disease. We hope that the description of this technique with its relative ease provides a feasible alternative to palliation in patients with pleural PMP disease.
Author contributions
Conceptualization; data curation; formal analy- sis; investigation; methodology; project administration. Validation; writing - original draft; writing-review & editing. Conceptualization; formal analysis; pro- ject administration. Conceptualization; data curation; formal analysis; investigation; methodology; project administration.
Data availability statement
The data that support the ndings of this study are available from the corresponding author, VJS, upon reasonable request.
References
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Moran BJ, Cecil TD. The etiology, clinical presentation, and manage- ment of pseudomyxoma peritonei. Surg Oncol Clin N Am. 2003;(3): 585603.
Pestieau SR, Esquivel J, Sugarbaker PH. Pleural extension of mucinous tumor in patients with pseudomyxoma peritonei syndrome. Ann Surg Oncol. 2000;(3):199203.
Chua TC, Yan TD, Yap ZL, Horton MD, Fermanis GG, Morris DL. Tho- racic cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy for pseudomyxoma peritonei. J Surg Oncol. 2009;(5): 2925.
Sugarbaker PH, Chang D, Stuart OA. Hyperthermic intraoperative thoracoabdominal chemotherapy. Gastroenterol Res Pract. 2012;: 623417.
B.H. Ltd. Dianeal dialysis uid; 2013.
Varun J. Sharma,* MBBS/BMedSc, MPH Jack Bhana,* CCP (Aust), FANZCP Simione Lolohea, BHB, MBChB, FRACS Felicity Meikle,* MBChB, MMed, FRACS *Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton, New Zealand, Waikato Institute of Surgical Education and Research, Hamilton, New Zealand and Department of General Surgery, Waikato District Health Board, Hamilton, New Zealand
doi: 10.1111/ans.17134
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