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The Journal of Thoracic and Cardiovascular Surgery, Vol 102, 1-9, Copyright © 1991 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
VW Rusch, S Piantadosi and EC Holmes
Malignant pleural mesothelioma is usually a fatal cancer for which
operation has been the mainstay of treatment because chemotherapy and
radiation are relatively ineffective. The choice of operation for malignant
pleural mesothelioma remains controversial. Extrapleural pneumonectomy has
been advocated because it allows complete removal of gross tumor and can be
associated with long-term survival. To evaluate extrapleural pneumonectomy,
we conducted a prospective multiinstitutional trial in patients with
biopsy-proved previously untreated malignant pleural mesothelioma. Criteria
for extrapleural pneumonectomy were (1) potentially completely resectable
unilateral disease by computed tomography scan, (2) predicted postresection
forced expiratory volume in 1 second greater than 1 L/sec, and (3) no other
major medical problems. Patients who were not candidates for extrapleural
pneumonectomy had a more limited operation with or without adjuvant therapy
or had nonsurgical treatment. From September 1985 to June 1988 83 eligible
patients (64 male, 19 female) were entered. The mean age for all patients
was 59.7 years. Only 20 of the 83 patients (24%) underwent extrapleural
pneumonectomy. Three of these 20 patients (15%) died postoperatively. The
recurrence-free survival was significantly longer for the patients
undergoing extrapleural pneumonectomy than for the other two groups (p =
0.03), but there was no difference in overall survival among the three
groups. In univariate analyses, epithelial versus sarcomatoid and mixed
histologic findings and platelet count less than 400,000 were associated
with a better overall survival (p = 0.02), and performance status
(Karnofsky less than 80) was predictive of recurrence (p = 0.02). In a
multivariate analysis, histologic findings, sex, age, extrapleural
pneumonectomy, weight loss, and performance status all had no significant
impact on survival. Extrapleural pneumonectomy was associated with a
greater likelihood of relapse in distant sites than were limited operation
and nonsurgical treatment. We conclude that (1) only a small proportion of
all patients with malignant pleural mesothelioma are candidates for
extrapleural pneumonectomy, (2) extrapleural pneumonectomy carries a
significant operative mortality and does not seem to improve overall
survival compared with more conservative forms of treatment, (3)
extrapleural pneumonectomy alters the patterns of relapse, and (4) factors
previously thought to have an impact on survival in other series did not
affect outcome in this trial.
ARTICLES
The role of extrapleural pneumonectomy in malignant pleural mesothelioma. A Lung Cancer Study Group trial
Memorial Sloan-Kettering Cancer Center, New York, N.Y.
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