Twice as Effective? Pressurized Intra-Thoracic Aerosol Chemotherapy: New Frontiers in Pleural Mesothelioma

Abstract

Pressurized intra-thoracic aerosol chemotherapy (PITAC) is a novel and promising strategy for the treatment of malignant pleural effusion (MPE). PITAC enables effective pleurodesis while potentially exerting an antineoplastic effect by delivering chemotherapeutic agents as a therapeutic aerosol into the thoracic cavity via a nebulizer. Our preliminary study involved nine patients with unresectable pleural mesothelioma (PM) treated with PITAC. Among them, one case was particularly emblematic for demonstrating notable oncological improvements in addition to well-known palliative benefits. This patient underwent two PITAC procedures, one year apart, without perioperative complications. Redo pleural biopsies from both previous and new sites revealed only fibrous tissue and inflammatory cells, with no evidence of malignancy. Beyond achieving pleurodesis, PITAC-by combining cytotoxic and sclerosing effects-may offer effective local antineoplastic control and represent a promising avenue for enhancing loco-regional therapy in PM.

Keywords: local antineoplastic control; malignant pleural effusion; mesothelioma; palliative care; pleural mesothelioma; pressurized intra-thoracic aerosol chemotherapy (PITAC).

Figure 1

PITAC procedure. (A): Patient in lateral decubitus position with two 12 mm balloon trocars: one placed in the seventh ICS along the mid-axillary line and the other in the fifth ICS along the anterior axillary line; intraoperative view of a 12 mm balloon trocar. (B): CE-certified nebulizer during the intrapleural nebulization of chemotherapeutic agents. (C): High-pressure injector connected to the nebulizer for sequential aerosolization of cisplatin and doxorubicin into the pleural cavity. (D): Operating room setup during the procedure, remotely monitored from outside. (E): Surgical smoke evacuation system with dual micro-particle filters; final placement of tubular and pigtail chest drains.

Figure 2

Imaging findings. (A): Chest CT before first PITAC showing right pleural effusion. (B): PET-CT before first PITAC showing two FDG-avid right pleural lesions (circled). (C): PET-CT before second PITAC showing effusion recurrence without FDG uptake. (D): Follow-up CT one year after second PITAC showing no effusion recurrence; biopsy site clips are circled.

Figure 3

Surgical views. (A): First PITAC: pleural disease with visible lesions (circled). (B): Second PITAC: fibrotic areas and new biopsies; prior biopsy sites marked with titanium clips (circled).

Figure 4

Histopathological features. (A): Parietal pleura showing a single layer of cuboidal mesothelial cells with mild cytological atypia (hematoxylin and eosin stain, 10× magnification). (B): Loss of BAP1 protein expression in tumoral mesothelial cells, with preserved staining in non-neoplastic inflammatory cells (immunohistochemical stain, 10× magnification). (C): Parietal pleura lacking mesothelial lining, with the presence of fibrous tissue and inflammatory cells only (hematoxylin and eosin stain, 10× magnification).