Neoadjuvant Chemotherapy Followed by Extrapleural Pneumonectomy in Malignant Pleural Mesothelioma: Is It Safe?

Abstract

TO THE EDITOR: We read with interest the article by Weder et al. They conducted a pilot study with neoadjuvant gemcitabine and cisplatin followed by extrapleural pneumonectomy in patients with malignant pleural mesothelioma. The response rate to neoadjuvant chemotherapy was 32% and extrapleural pneumonectomy was performed in 16 of 19 patients. Thirteen patients received postoperative radiotherapy. Weder et al concluded that extrapleural pneumonectomy can be performed safely after neoadjuvant chemotherapy in an experienced center. Unfortunately, this conclusion is somewhat incorrect. Although Weder et al reported no perioperative death, the perioperative morbidity rate was quite high. Perioperative morbidity was observed in seven of the 16 patients (43.75%) on whom extrapleural pneumonectomy was performed: pulmonary embolism in one patient, chylothorax in three patients, thrombosis of the brachiocephalic vein in one patient, bronchopleural fistula in one patient, and pyothorax in one patient. Two patients were operated on for the treatment of these operative complications. Two patients were hospitalized for bleeding intrathoracically and retroperitoneally. It is unclear whether neoadjuvant chemotherapy is responsible for this high rate of perioperative morbidity. Therefore, the safety of this treatment modality should be questioned before further studies on uncured malignant pleural mesothelioma. Quality of life related to the treatment becomes more important in this group of patients because of the high rate of perioperative morbidity, and Weder et al should have assessed this in their study. On the other hand, although Weder et al reported in the abstract of their article that the major toxicity of neoadjuvant gemcitabine and cisplatin was thrombocytopenia, if we consider their Table 2, it is seen that grade 3 and 4 leukopenia and neutropenia are more frequent than thrombocytopenia. Gungor Utkan, Bulent Yalcin, and Abdullah Buyukcelik Department of Medical Oncology, Ankara University School of Medicine, Ibni Sina Hospital, Sihhiye, Ankara, Turkey.