Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy☆
Introduction
Malignant pleural mesothelioma (MPM) is an aggressive and rapidly fatal malignancy of the pleura. Conservative therapy of MPM results in median survival of 7 months after diagnosis [1]. Generally known single-modality therapies alone show disappointing results. Trimodality therapy seems to be the best treatment for malignant pleural mesothelioma [2].
The role of surgical resection in the management of MPM is still controversial. The criteria used to select patients for either Extrapleural Pneumonectomy (EPP) or Pleurectomy/Decortication (P/D) are dependent not only on the cardio-pulmonary status of the patient, tumor stage and intraoperative findings but also reflect the surgeons’ philosophy. There are no established guidelines. Radical Pleurectomy (RP) competes against EPP as surgical therapy modality. Both EPP and RP are cytoreductive treatment options with the aim to remove all gross disease and to achieve macroscopic complete resection [2].
Originally P/D was a palliative option for controlling pleural effusion [3]. But lung-sparing surgery for MPM seems to be an alternative for patients unsuitable or unwilling to undergo EPP in a multimodality therapy concept [4]. In the era of multimodality therapy of MPM RP could have an important role as a surgical philosophy of limiting the procedure related morbidity and mortality and thus allowing patients to achieve maximal benefit from all aspects of a multimodality concept.
Most studies evaluating multimodality therapies for MPM are based on retrospective analyses and their interpretation is difficult because of inhomogeneous patient groups studied. The aim of our prospective study was to analyze the feasibility and describe the long-term outcomes of patients treated with RP as surgical therapy modality in a standardized trimodality therapy concept.
Section snippets
Study design
All consecutive patients with histological diagnosis of MPM were enrolled in our prospective database. All patients were evaluated for trimodality therapy, including surgery with RP followed by four cycles of systemic chemotherapy with Cisplatin (75 mg/m2) and Pemetrexed (500 mg/m2), as well as radiation therapy 4–6 weeks after operation. The primary outcome was survival. The secondary outcomes included morbidity and mortality. The local Ethics Board approved this study. All patients gave written
Patient's characteristics
From November 2002 to October 2007, 35 of 102 consecutive patients with histological diagnosis of MPM met the inclusion criteria and were prospectively enrolled in this study. Most of the excluded patients were treated previously for MPM or were not eligible for multimodality treatments. All 35 patients underwent thoracoscopic evaluation because of unilateral pleural effusion. The mean age was 65.0 ± 8.1 years (range 47–81 years). Twenty-nine patients were male (82.9%). Median pre-surgical forced
Discussion
In this pilot investigation of RP as surgical therapy modality in a standardized trimodality therapy concept including adjuvant Cisplatin/Pemetrexed and radiotherapy, we found promising results in terms of treatment-related morbidity and mortality and long-term survival. Combined with the fact that this less invasive surgical treatment approach was feasible in all stages of MPM this study adds new information regarding the role of surgery in the management of MPM.
EPP is the most aggressive
Conclusions
A trimodality therapy concept with RP as surgical strategy demonstrates promising results in terms of treatment-related morbidity and mortality and long-term survival. This multimodality approach is feasible in all stages of MPM. We propose that a surgical philosophy of limiting the procedure related morbidity while achieving comparable cytoreductive results allows patients to maintain physiological reserve to be eligible for multimodality treatment options in the long-term. We believe that RP
Conflict of interest statement
There is no potential conflict of interest to disclose.
References (26)
Macroscopic complete resection: the goal of primary surgery in multimodality therapy for pleural mesothelioma
J Thorac Oncol
(2006)- et al.
Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy
Chest
(1995) - et al.
Multicenter trial of neo-adjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma
Ann Oncol
(2007) - et al.
Important prognostic factors in patients with malignant pleural mesothelioma managed surgically
Ann Thorac Surg
(1999) - et al.
Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies
J Thorac Cardiovasc Surg
(2004) - et al.
Malignant pleural mesothelioma: surgical management in 285 patients
Ann Thorac Surg
(2008) - et al.
Radical pleurectomy/decortication and intraoperative radiotherapy followed by conformal radiation with or without chemotherapy for malignant pleural mesothelioma
J Thorac Cardiovasc Surg
(2002) - et al.
Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients
J Thorac Cardiovasc Surg
(1999) - et al.
Second-line (post-study) chemotherapy received by patients treated in the phase III trial of pemetrexed plus cisplatin versus cisplatin alone in malignant pleural mesothelioma
Ann Oncol
(2005) - et al.
A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma
J Thorac Cardiovasc Surg
(2001)
Hemithoracic radiation therapy after pleurectomy for malignant pleural mesothelioma
Int J Radiat Oncol Biol Phys
Local recurrence of tumor at sites of intervention in malignant pleural mesothelioma
Lung Cancer
Survival after conservative (palliative) management of pleural malignant mesothelioma
J Surg Oncol
Cited by (112)
Pleurectomy and decortication are associated with better survival for bicavitary cytoreductive surgery for mesothelioma compared with extrapleural pneumonectomy
2023, Journal of Thoracic and Cardiovascular SurgeryDiagnostic Laparoscopy Improves Staging of Malignant Pleural Mesothelioma With Routine Positron Emission Tomography Imaging
2021, Annals of Thoracic SurgerySurgical Risk and Survival Associated With Less Invasive Surgery for Malignant Pleural Mesothelioma
2019, Seminars in Thoracic and Cardiovascular SurgeryInvestigation of the appropriate viscosity of fibrinogen in repairing pleural defects using ventilation and anchoring in an ex vivo pig model
2024, Journal of Cardiothoracic SurgeryCHST4 Gene as a Potential Predictor of Clinical Outcome in Malignant Pleural Mesothelioma
2024, International Journal of Molecular Sciences
- ☆
Presented in part at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008, and at the European Multidisciplinary Conference in Thoracic Oncology, Lugano, Switzerland 1–3 May, 2009.