Chest
Volume 112, Issue 4, Supplement, October 1997, Pages 272S-275S
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Multimodality Therapy for Malignant Pleural Mesothelioma

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Mesothelioma is a rare disease for which neither single modality nor bimodality therapy improves survival. For this reason, from 1980 to 1995, we used trimodality therapy in an attempt to improve survival in selected patients at Brigham and Women’s Hospital and Dana-Farber Cancer Institute. One hundred twenty patients underwent trimodality treatment involving extrapleural pneumonectomy followed by combination chemoradiotherapy. Twenty-seven women and 93 men (mean age, 56 years) were evaluable for response and treatment-related morbidity. The operative mortality rate was 5%, and 22% of patients experienced major morbidity. Cell type and nodal status were significant prognostic variables. The respective 2- and 5-year survival rates were 45% and 22% overall, 70% and 37% for patients with epithelial cell type, 20% and 0% for patients with sarcomatous or mixed-histologic-type tumors, and 74% and 39% for patients who were node-negative with epithelial histologic type. Positive resection margins impacted survival only in the case of full-thickness, transdiaphragmatic invasion. A revised staging system stratified survival with median intervals of 22, 17, and 11 months for stages I, II, and III disease, respectively (p=0.04). Thus, extrapleural pneumonectomy with adjuvant therapy is appropriate and effective treatment for patients with stage I disease according to the revised staging system.

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Materials and Methods

Thus, in our study, candidate patients were evaluated on the basis of spirometry, oximetry, arterial blood gases, chest radiograph and CT, chest MRI (after 1988), ventilation-perfusion scan (if FEV1 was <1 L), and echocardiography. Patients without medical contraindications whose tumor was clinical stage I according to Butchart et al14 and considered completely resectable were candidates for trimodality therapy if they had an Eastern Cooperative Oncology Group performance status of 0 or 1 and

Results

Median length of hospital stay following extrapleural pneumonectomy was 9 days (range, 5 to 101 days). Perioperative (30-day) mortality was 5%, resulting from myocardial infarction (two patients), pulmonary embolus (two), respiratory failure (one), and cardiac herniation through the pericardial defect (one). Morbidity was 22%. Fifteen patients (12.5%) experienced one or more of the following major complications: hemorrhage (four patients), respiratory failure (four), pneumonia (five), disrupted

Discussion

In appropriately selected patients, extrapleural pneumonectomy with adjuvant chemotherapy and radiotherapy is safe and effective treatment for malignant pleural mesothelioma. Overall median survival (21 months, Fig 1) of patients receiving this trimodality therapy is superior to that obtained with single-modality therapy. Nodal involvement, cell type, and transdiaphragmatic invasion are prognostic factors that stratify survival of patients treated in this manner. The results described herein

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Reprint requests: David J. Sugarbaker, MD, FCCP, Division of Thoracic Surgery, Brigham and Womens Hospital, 75 Francis St, Boston, MA 02115

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