Extended Pleurectomy-Decortication–Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years

摘要

Background The purpose of this study was to assess survival for patients with malignant pleural mesothelioma (MPM), epithelial subtype, utilizing extended pleurectomy-decortication combined with intraoperative photodynamic therapy (PDT) and adjuvant pemetrexed-based chemotherapy.;Methods From 2005 to 2013, 90 patients underwent lung-sparing surgery and PDT for MPM. All patients had a preoperative diagnosis of epithelial subtype, of which 17 proved to be of mixed histology. The remaining 73 patients with pure epithelial subtype were analyzed. All patients received lung-sparing surgery and PDT; 92% also received chemotherapy. The median follow-up was 5.3 years for living patients.;Results Macroscopic complete resection was achieved in all 73 patients. Thirty-day mortality was 3% and 90-day mortality was 4%. For all 73 patients (89% American Joint Commission on Cancer stage III/IV, 69% N2 disease, median tumor volume 550 mL), the median overall and disease-free survivals were 3 years and 1.2 years, respectively. For the 19 patients without lymph node metastases (74% stage III/IV, median tumor volume 325 mL), the median overall and disease-free survivals were 7.3 years and 2.3 years, respectively.;Conclusions This is a mature dataset for MPM that demonstrates the ability to safely execute a complex treatment plan that included a surgical technique that consistently permitted achieving a macroscopic complete resection while preserving the lung. The role for lung-sparing surgery is unclear but this series demonstrates that it is an option, even for advanced cases. The overall survival of 7.3 years for the node negative subset of patients, still of advanced stage, is encouraging. Of particular interest is the overall survival being approximately triple the disease-free survival, perhaps PDT related. The impact of PDT is unclear, but it is hoped that it will be established by an ongoing randomized trial.;Malignant pleural mesothelioma (MPM) is a virulent, incurable cancer. Chemotherapy is the standard of care, with survival usually cited in the 12- to 18-month range [1, 2, 3]. As a curative microscopic (R0) resection is essentially impossible for MPM, the goal of surgery is to achieve a macroscopic complete resection (MCR) performed as part of a multimodal treatment plan. Surgery remains controversial for MPM because it is an operation of considerable magnitude that is, technically, palliative and also because reported surgical results are often similar to nonsurgical results.Still, there do appear to be patients who benefit significantly more from a surgery-based approach than would be expected from chemotherapy alone, emphasizing the importance of patient selection. The art of patient selection for MPM surgery extends beyond the current staging system and includes prognosticators such as sex, platelet count, pain, tumor volume, and in particular, the subtype of the cancer [4, 5, 6, 7, 8, 9, 10].Our surgery-based approach has always included intraoperative photodynamic therapy (PDT), but initially included all subtypes of disease and both surgical approaches. We then switched exclusively to extended pleurectomy-decortication (EPD) after comparing our outcomes of extrapleural pneumonectomy (EPP) versus EPD [11][11]. Examining a larger cohort of EPD patients, we found that histologic subtype was the main prognosticator, but the results still appeared promising for patients with large-volume disease, advanced stage, and bulky adenopathy [12][12]. This study reports the results of EPD, intraoperative PDT, and chemotherapy on 73 patients limited to epithelial histology but including the unfavorable prognosticators of advanced stage, nodal disease and bulk.Jump to SectionPatients and MethodsSurgical ProcedureFollow-Up and StatisticsResultsComplicationsSurvivalCommentStudy LimitationsStudy StrengthsFollow-upSurgeryTeamworkUnique dataDiscussion of resultsValue of this studyChallenges in the fieldWhere to goDiscussionReferences;This study is