A multimodality treatment for malignant pleural mesothelioma patients with or without lymph node metastases.

Abstract

7043 Background: Recent surgically based series have reported significantly worse survival for patients with malignant pleural mesothelioma (MPM) and nodal metastases, and suggested that node positive patients may not be good surgical candidates. Based upon our previous experience with photodynamic therapy (PDT) in treating MPM, we designed a multimodal treatment program and elected to include patients with suspected ipsilateral nodal metastases. Methods: 38 patients with localized MPM (ages 27-81) were treated from 2/2004 to 6/2009. 12 patients were treated on a phase II study and 26 additional consecutive patients were treated as per protocol. Therapy included cytoreduction with radical pleurectomy (RP) or extrapleural pneumonectomy (EPP), intraoperative PDT and adjuvant pemetrexed-based chemotherapy ± radiotherapy. RP was employed in more recent years for all patients, regardless of tumor bulk. Results: A macroscopic complete resection was achieved in all 38 patients (14 EPP/24 RP). 30 patients had locally advanced (AJCC stage III/IV) and 10 patients had nonepithelial MPM. There were 3 postoperative deaths (2 EPP/1 RP). 32 patients received chemotherapy (10 preop/22 postop) and 14 patients received postop radiotherapy. With a median follow-up of 15 months, median PFS and OS were 13 months (36±9% at 2 years) and 26.5 months (54 ±9% at 2 years), respectively. 15 have experienced disease progression, with a first site of failure being local in 6, distant in 6 and local + distant in 3. There was no difference in OS (log rank p=0.88) or PFS (log rank p=0.41) for the 20 patients with positive lymph nodes (3 N1, 17 N2) compared to the 18 N0 patients. Conclusions: The 26.5 month median OS compares favorably with other series, particularly since our patients were 79% stage III/IV and 26% nonepithelial histology. With a multimodality approach including intraoperative PDT, the majority of our patients had a lung sparing surgery but the reason for the surprising lack of impact of nodal metastases remains incompletely understood. We conclude that this multimodal approach is deserving of further study and that future studies of this approach should not exclude MPM patients with suspected nodal metastases. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Axcan Pharmaceuticals