Elsevier

Lung Cancer

Volume 81, Issue 2, August 2013, Pages 241-246
Lung Cancer

Radical pleurectomy and chemoradiation for malignant pleural mesothelioma: The outcome of incomplete resections

https://doi.org/10.1016/j.lungcan.2013.04.019Get rights and content

Abstract

Background

The type of surgery (radical pleurectomy (RP) vs. extrapleural pneumonectomy (EPP)) remains controversial for malignant pleural mesothelioma (MPM). Macroscopic complete resection (MCR) is a key prognostic factor. It is unclear, if patients undergoing incomplete RP within a standardized multimodality treatment protocols have any advantage in terms of survival and if EPP could theoretically have avoided incomplete resections (R2).

Methods

Eighty-eight patients underwent RP followed by chemoradiation from 2002 to 2011 within a prospective multimodality treatment study at a single institution. MCR were compared to R2 within this patient cohort retrospectively. EPP eligibility was assessed retrospectively based on preoperative cardiopulmonary testing and theoretical feasibility to achieve MCR. Kaplan–Meier analyses, log-rank test and Cox regression analyses were used to estimate survival and to determine predictors of survival.

Results

For the complete patient cohort, median survival (MS) was 26.3 months (mo). MCR could be achieved in 64.8% (57/88). Compared to MCR patients, R2-patients (n = 31, 35.2%) had an inferior overall survival (MS 13 vs. 33 mo, P < .0001), shorter progression-free-survival (MS 9 vs. 16 mo, P < .0001) and inferior survival after disease progression (MS 4 vs. 11 mo; P < .0001), respectively. R2 was associated with advanced p-T-Status (P < .0001), p-N-Status (P = 0.046) and p-IMIG stage (P < .0001). No difference could be observed with regard to age, histology, laterality, surgical morbidity and mortality, respectively. Only 3 out of 88 patients (3.4%) would have been eligible for EPP to achieve MCR. Not resectable T4-disease and impaired cardiopulmonary reserves were the main reasons for ineligibility for EPP in 35.5% (11/31) and 48.4% (15/31), respectively.

Conclusions

R2 in patients undergoing RP is associated with inferior outcomes. Only very selected cases would have qualified for EPP to achieve MCR. EPP might be an important surgical extension in selected patients to achieve MCR. There is a need for further investigation of effective intrapleural additive treatment options for patients undergoing R2.

Introduction

Malignant pleural mesothelioma (MPM) is a rapidly fatal malignant disease originating from the mesothelial surfaces of the pleura. Macroscopic complete resection (MCR) is the goal of surgery and seems to have the most significant effect on survival in patients undergoing multimodality treatment for MPM [1]. However, the type of surgery for MPM depends not only on patients’ cardio-pulmonary reserves, disease distribution and histology of the disease, but also on surgeons’ preference and philosophy.

Either surgery in terms of extrapleural pneumonectomy (EPP), lung-sparing radical pleurectomy (RP), pleurectomy/decortication (PD) or extended pleurectomy/decortication (EPD) might achieve MCR. Despite that, it is unclear, if patients undergoing incomplete RP (R2) within a standardized multimodality treatment protocols have any advantage in terms of survival and if EPP should be carried out in these cases to avoid R2.

There is a lack of data with regard to lung-sparing RP for MPM intended to achieve MCR but resulted in R2. Thus, the present study intends to analyze R2 in patients undergoing RP for MPM as a prognosticator on overall survival.

Section snippets

Methods

All consecutive patients with diagnosis of MPM were evaluated prospectively for trimodality therapy with curative intent between 2002 and 2011 as reported previously [2]. The study (ClinicalTrials.gov identifier NCT01343264) was approved by the institutional review board. Written consent was obtained from each study patient. The study was conducted according to the revised Declaration of Helsinki and the requirements of good clinical practice. Macroscopic complete resections (MCR group) were

Patient characteristics

Eighty-eight out of 206 consecutive patients with histological confirmed diagnosis of MPM were included in the study and underwent RP. Surgical morbidity and mortality were 27.3% (24/88) and 2.3% (2/88), respectively. The most common complications were pneumonia (6/88, 6.8%), prolonged air leak (5/88, 5.7%) and atrial fibrillation (4/88, 4.5%), respectively. Neutropenic fever and sepsis during chemotherapy caused another death. Thus, the treatment related mortality from any cause was 3.4%

Discussion

In this retrospective analysis of a prospective evaluated standardized trimodality therapy concept including RP upfront followed by adjuvant cisplatin/pemetrexed and radiotherapy, we found out that R2 were associated with inferior outcomes and only very selected cases would have qualified for EPP to achieve MCR. R2 was correlated to advanced p-T-Status, p-N-Status and p-IMIG stage.

All surgical efforts focus on achieving MCR. It is not our philosophy that all patients benefit from surgery. This

Conclusions

R2 in patients undergoing RP are associated with inferior outcomes. The present results might help to identify a high-risk group of patients undergoing R2 and futile surgery. Only very selected cases (less than 4% in this series) would have qualified for EPP to achieve MCR. EPP might be an important surgical extension in selected patients to achieve MCR. There is a need for further investigation of effective intrapleural additive treatment options for patients undergoing incomplete resections.

Conflict of interest statement

None declared.

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