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