A Stanford team performed a specialized procedure for pleural mesothelioma for the very first time in North America. It is known as pressurized intrathoracic aerosol chemotherapy (PITAC), and it delivers chemotherapy directly to the chest as a pressurized mist. One doctor knows it as “spray paint chemo.” PITAC is minimally invasive while still fighting the aggressive cancer. It can reach hard-to-reach places of the chest better than traditional chemotherapy for mesothelioma. PITAC may fill a gap between major surgery and simple symptom control. PITAC could be an important option for patients ineligible for more radical surgeries. It can both treat cancer and relieve uncomfortable symptoms like pleural effusions, improving quality of life.
PITAC stands out because more patients may be eligible for it compared to radical surgery. It has very early promise and very low harm compared to higher-risk operations. This is important because pleural mesothelioma decisions are usually difficult and highly individualized. Some patients are not well enough to tolerate a major surgery such as pleurectomy/decortication. The role of surgery for pleural mesothelioma has been at the center of debate since the MARS 2 trial results were released. The results put the survival benefits of pleurectomy/decortication surgery in question. Nuances have been found in the discussion, finding that with careful patient selection, lung-sparing surgery can have positive outcomes and very low mortality. PITAC may now expand options for those patients who do not qualify for pleurectomy/decortication.
PITAC is best suited for mesothelioma patients with pleural effusion and cancer spread contained in the chest, a study from 2025 found. Based on these criteria, the first patient in the PITAC study was a strong patient for the study. The patient’s tumor burden was low but was suffering from symptoms because she had effusions. The patient, a woman in her 70s, had previously undergone surgery and HIPEC for peritoneal mesothelioma. She had been without evidence of disease for more than a year before developing a pleural effusion that raised concern for mesothelioma in her chest. The patient underwent surgery, including a pleural biopsy and pleurodesis. Even though she saw no evidence of pleural disease, blind biopsies came back positive for mesothelioma. The team hoped the procedure would treat the effusion and possibly delay systemic therapy.
PITAC was performed through a standard video-assisted thoracic surgery approach using two small ports. The chemo is misted into the chest, given time to absorb into the tissue and then a chest tube is placed to complete the procedure. PITAC patients usually go home within about two days, and pain is generally manageable. A pleurodesis, which manages the fluid buildup of a pleural effusion but does not treat cancer directly, has a typical hospital stay of about three to five days. P/D surgery with hyperthermic intrathoracic chemotherapy usually involves a hospital stay of seven to ten days and a surgical recovery of several months.
PITAC can be a good option for patients who want both palliative therapies to stay as comfortable as possible and to remove, kill, or slow cancer cells. Tumor removing (cytoreductive) surgeries and cancer targeted chemotherapy (cytotoxic) are often paired with P/D and HITHOC. PITAC offers similar benefits, but with a minimally invasive procedure. The treatment offers both palliation and cytotoxicity to buy you more time. For patients with extensive pleural disease, some doctors still prefer P/D with HITHOC. PITAC may be more appropriate for patients who are not healthy enough for that level of intervention. It may also benefit patients for whom P/D would not actually be more challenging. This includes those with very little visible disease, where removing the pleural lining is technically more difficult.
PITAC is being offered through a registry by Stanford who is using clinical judgment to select patients. The team at Stanford is tracking quality-of-life measures and closely monitoring whether pleural effusions recur, which are the easiest early signs to follow. The next step is a phase 1 pilot study focused on safety. If effusions stay controlled and quality of life holds, future research can take on bigger questions about disease control and survival. It will be a huge win if the study does not harm patients and the treatment combats the disease and prolongs life.
Researchers need to be cautiously optimistic about new treatments like PITAC. The data is promising so far on safety, but there are unanswered questions about long-term outcomes. Enduring effectiveness is a concern for pleural patients who can experience mesothelioma recurrence. It is not known how lasting PITAC results will be. Side effects are also a concern. The main thing that chemo can affect is the kidneys. While PITAC uses a targeted mist rather than the usual delivery through the bloodstream, some of the chemo drugs can be absorbed through the pleural surface in the chest. PITAC has very little downside. The potential of the treatment is to open options to patients who are ineligible for aggressive surgery but want more of an intervention plan than chemo alone.
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