Open lung-sparing surgery for malignant pleural mesothelioma: the benefits of a radical approach within multimodality therapy.

OBJECTIVE

To identify the optimal debulking procedure in patients with malignant pleural mesothelioma who are not suitable for extrapleural pneumonectomy (EPP).

METHODS

We reviewed 102 consecutive patients (93 male; 9 female, mean age 63 years) who were not suitable for EPP because of either advanced tumour stage or suboptimal fitness. Patients underwent either a non-radical tumour decortication to obtain lung expansion (group NR) or latterly a radical pleurectomy/decortication to obtain macroscopic tumour clearance (group R). We analysed the comparative perioperative courses and long-term survival.

RESULTS

The two groups were similar for age and gender distribution but epithelioid type was more predominant in group R: 78% compared to 55% epithelioid in group NR. Thirty-day mortality was similar (5.9% in group R and 9.8% in the group NR, p=0.36) but 90-day mortality was significantly higher in the group NR (29.4% vs 9.8% in group R, p=0.012). More patients in group R received adjuvant chemotherapy (65% vs 28%, p=0.000) and radiotherapy (65% vs 26%, p=0.000). Median survival for all cell types was significantly higher in group R (15.3 months vs 7.1 months, p<0.000). Group R survival rates at 1, 2, 3 and 4 years were 53, 41, 25 and 13%, respectively while for group NR they were 32, 9.6, 2 and 0%, respectively. For epithelioid cell type there was still a significant median survival advantage in group R (25.4 months vs 10.2 months, p<0.000), but there was no difference for sarcomatoid (9.3 months vs 3.2 months, p=0.16) or biphasic cell types (9.4 months vs 7 months, p=0.38).

CONCLUSION

If a patient with epithelioid MPM is fit enough to tolerate a thoracotomy then macroscopic clearance of the tumour is the preferred option as part of a multimodality regime including chemotherapy.