Elsevier

Lung Cancer

Volume 77, Issue 1, July 2012, Pages 151-155
Lung Cancer

Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: A harmful procedure

https://doi.org/10.1016/j.lungcan.2011.12.009Get rights and content

Abstract

The effects on long-term post-operative quality of life (QoL) and disease-control in malignant pleural mesothelioma (MPM) of extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D) are compared. Seventy-seven patients affected by early-stage MPM received EPP (40) or P/D (37) associated with multimodal treatment between 1998 and 2009 at our institution. The last consecutive 39 (19 EPP and 20 P/D) were asked to answer the EORTC-QLQ-C30 questionnaire at baseline and at 6- and 12-months after treatment completion to evaluate the impact on QoL of both procedures. QoL evaluation was stopped at recurrence demonstration. Twenty-five (62%) EPP vs 9 (24%) P/D patients (p = 0.002) had in-hospital major complications, and 2/40 (5%) EPP vs no one P/D patients died after surgery. Both procedures caused a significant impairment of all the considered variables of the EORTC-QLQ-C30 questionnaire after treatment completion; only P/D patients returned at baseline levels after12 months. EPP patients had a worse long-term post-operative QoL when compared with P/D. Median post-operative disease-free period was longer for EPP patients (14 vs 11 months) whereas the residual life to death period after recurrence detection was significantly longer for P/D patients (13 vs 9 months) (p = 0.01). Median long-term survival was longer, even not significant, for P/D patients (25 vs 20 months). MPM patients submitted to EPP had a higher post-operative complication rate, a worse long-term QoL, a shorter residual life time after recurrent disease, despite a similar long-term survival when compared to P/D.

Introduction

Malignant pleural mesothelioma (MPM) is a relatively rare, relentless and often fatal malignancy commonly associated with asbestos exposure. MPM worldwide incidence continues to rise and it is expected to kill about 9000 men in Europe in 2018 [1].

Therapy for MPM in the past decades included chemotherapy, immunotherapy, photodynamic therapy, radiation therapy, surgery and supportive care. Even utilised in a multimodal association, these therapeutic options have not demonstrated an effective impact on disease control and until now long-term survival remains poor [2].

At today, principal unsolved questions are if surgery may really offer a survival advantage in MPM patients (even in a multimodal treatment protocol) and which is the better surgical technique to be proposed to MPM patients (i.e. extrapleural pneumonectomy vs lung-sparing procedures).

Extrapleural pneumonectomy has been described in the past by the more accurate procedure to warrant the expected complete removal of the disease [3]. The post-operative course is frequently disseminated by major complications [3], and adverse events and the long-term post-operative referred quality of life is frequently impaired.

We carried out a prospective not-randomised study to evaluate the impact on long-term quality of life of two different surgical procedures (extrapleural pneumonectomy and pleurectomy/decortication) carried out in MPM patients. Results in terms of efficacy of long-term disease control and referred quality of life are discussed.

Section snippets

Materials and methods

Between January 1998 and December 2009, 423 patients were diagnosed to be affected by malignant pleural mesothelioma (MPM) by video-assisted thoracoscopic (VAT) pleural biopsy at our institution. One-hundred seventy-four patients affected by demonstrated epithelial MPM received a multimodal treatment protocol involving surgical resection of the disease. Pathological “early stage” MPM was confirmed after surgical excision in 77 patients: 16 were at stage I and 61 at stage II.

Forty out of 77

Postoperative in-hospital complications and mortality

EPP group: Twenty-five out of 40 patients (62%) had postoperative complications: 17 atrial fibrillation, 4 bleedings requiring re-operation, 2 pneumonia, 1 adult respiratory distress syndrome, 1 broncho-pleural fistula with empyema, 1 cerebral ischemic attack, 1 pulmonary embolism, 1 gastric hernia after diaphragmatic prosthesis dislocation. No significant differences in post-operative morbidity were recorded after the utilisation of neoadjuvant poli-chemotherapy (after January 2000). Two

Discussion

Even if the incidence of malignant pleural mesothelioma is increased during the last decades because of the effect of a previous asbestos work exposure or environmental pollution, this tumour remains a rare disease [1]. Even a rare disease, its tremendous natural evolution because of loco-regional symptoms has ever stimulated physicians and surgeons to develop treatment options for their patients. Since the first publication of Butchart et al. [6], surgical exeresis has been considered part of

Conclusions

Even if not randomised, the present study suggests that P/D in a multimodal protocol is characterised by a lower morbidity and mortality, warranting a better QoL up to recurrent disease and a longer survival after recurrence when compared with EPP. The identification of early stage disease is frequently the consequence of an aggressive diagnostic approach which proposes pleural biopsy by pleuroscopy or video-assisted thoracoscopy to all patients with a minimal suspect of MPM on the basis of

Conflict of interest statement

No conflict of interest to be declared.

Acknowledgements

Authors are grateful to Professor Tom Treasure (Clinical Occupational Research Unit, University College of London, UK) for his gentle cooperation during the manuscript preparation and writing assistance, and give sincere thanks to Professor Giuliano Maggi (Professor Emeritus of Thoracic Surgery, University of Torino, Italy) for his precious teaching in MPM surgery.

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