Elsevier

The Annals of Thoracic Surgery

Volume 98, Issue 5, November 2014, Pages 1748-1754
The Annals of Thoracic Surgery

Original article
General thoracic
Extrapleural Pneumonectomy After Induction Chemotherapy: Perioperative Outcome in 251 Mesothelioma Patients From Three High-Volume Institutions

Presented at the Poster Session of the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2014.05.071Get rights and content

Background

Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.

Methods

251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.

Results

The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p = 0.001 and p < 0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p = 0.001 and p < 0.0005; and p = 0.002 and p < 0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p = 0.01) and after longer operations (p < 0.0005). Empyema (p < 0.0005) and acute respiratory distress syndrome (p = 0.02) were associated with longer duration of operation.

Conclusions

EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.

Section snippets

Patients and Methods

The present retrospective analysis of 251 MPM patients was set up in a three-institutional setting and included the results of the outcome in MPM patients at the University of Zurich (cohort 1, n = 137), the Division of Thoracic Surgery at the University of Toronto (cohort 2, n = 60), and the University of Vienna (cohort 3, n = 54) from 1999 until 2012. Approval of the institutional review board and patient consent was obtained in all three centers. The MPM patients underwent mostly three

Results

Between 1999 and 2012, a total of 251 patients underwent platinum-based induction chemotherapy followed by EPP at the three different institutions. The characteristics of the three cohorts are shown in Table 1. Significant differences between all cohorts were observed in the distribution of gender (Fisher’s exact test, p = 0.02), body mass index (independent samples Kruskal-Wallis test, p = 0.006), smoking habits (Fisher’s exact test, p < 0.0005), pulmonary function test (independent samples

Comment

In this retrospective analysis, we demonstrated that perioperative morbidity and mortality of EPP after induction chemotherapy in 251 consecutively treated patients in three dedicated centers for mesothelioma research and treatment could be maintained with an acceptable rate. Regarding the trend of the past 14 years, there was no obvious learning curve comparing early with late periods, but indeed fewer patients died during the early postoperative phase, and in one center (cohort 1) no patient

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    Drs Lauk and Hoda contributed equally to this work.

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