Intraoperative Photodynamic Therapy After Pleuropneumonectomy for Malignant Pleural Mesothelioma

Abstract

We thank Bonnette et al for the valuable comments on our study.1Schouwink H Rutgers ET Van Der Sijp J et al.Intra-operative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; 120: 1167-1174Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar In their reaction, they addressed the study of Sugarbaker et al,2Sugarbaker DJ Flores RM Jaklitsch MT et al.Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients.J Thorac Cardiovasc Surg. 1999; 117: 54-65Abstract Full Text Full Text PDF PubMed Scopus (800) Google Scholar using a trimodality approach of extrapleural pneumonectomy combined with chemotherapy and radiotherapy and some aspects of the use of photodynamic therapy (PDT) after resection. In this study, the perioperative mortality is only 3.8% and the median survival is 19 months. Although the survival was not calculated on an intention-to-treat basis, results were better than what is generally achieved with the combination surgery and PDT.1Schouwink H Rutgers ET Van Der Sijp J et al.Intra-operative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; 120: 1167-1174Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar,3Moskal TL Dougherty TJ Urschel JD et al.Operation and photodynamic therapy for pleural mesothelioma: 6-year follow-up.Ann Thorac Surg. 1998; 66: 1128-1133Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar,4Pass HI Temeck BK Kranda K et al.Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunotherapy for malignant pleural mesothelioma.Ann Surg Oncol. 1997; 4: 628-633Crossref PubMed Scopus (160) Google Scholar At least three factors may have been responsible for the difference in treatment outcome. Firstly, the combination surgery, chemotherapy, and radiotherapy may have a better antitumor activity, leading to better tumor control with acceptable toxicity. Secondly, the use of histologic assessment to direct radiotherapy to locations of irradical tumor resection seems an elegant way to treat those locations at risk more effectively. Finally the use of MRI may have improved prediction of resectability, which is considered difficult by many investigators. In the treatment protocol, with surgery and PDT used by Dr. Bonnette, which is comparable to ours, the esophagus, bronchial and vascular stumps, and pericardium were (partly) shielded from the laser light. This may have the advantage to avoid potential lethal complications (esophageal perforation, bronchial fistula, and myocardial infarction), which occurred in our study. However, organs shielded from light do not receive the additional PDT treatment, and may therefore be at risk for local tumor recurrence. In our opinion, the study of Bonnette et al is of particular importance because it can provide information on the risk of local recurrences. Improvement of many issues of PDT in combination with surgery, such as patient selection and illumination of the diaphragmatic gutter, still seems possible.1Schouwink H Rutgers ET Van Der Sijp J et al.Intra-operative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; 120: 1167-1174Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar,5van Veen RLP Schouwink JH Star WM et al.Wedge-shaped applicator for additional light delivery and dosimetry in the diaphragmal sinus during photodynamic therapy for malignant pleural mesothelioma.Phys Med Biol. 2001; 46: 1873-1883Crossref PubMed Scopus (12) Google Scholar These improvements may better determine the exact place and indication of PDT-mediated therapy in malignant pleural mesothelioma. Intraoperative Photodynamic Therapy After Pleuropneumonectomy for Malignant Pleural MesotheliomaCHESTVol. 122Issue 5PreviewWe read with great interest the article by Schouwink et al (October 2001)1 about intraoperative photodynamic therapy after pleuropneumonectomy for the treatment of patients with pleural mesothelioma. Full-Text PDF