Pleurectomy Decortication Research Articles

Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma

BackgroundFew studies have focused on quality of life (QoL) after treatment of malignant pleural mesothelioma (MPM). There are still questions as to which surgical procedure, extrapleural pneumonectomy (EPP) or pleurectomy decortication (P/D) is most effective and results in better survival outcomes, involves fewer complications, and results in better QoL. Here we performed a literature review on MPM patients to assess and compare QoL changes after P/D and EPP.MethodsResearch articles concerning QoL after mesothelioma surgery were identified through May 2018 in Medline. For inclusion, studies were 1) cohort or randomized controlled trials (RCT) design, 2) included standardized QoL instruments, 3) reported QoL measurement after surgery, 4) described the type of surgery performed (EPP or P/D), 5) were written in English. Measures of lung function (FEV1, FVC) and measures from the EORTC-C30 were compared 6 months following surgery with preoperative values.ResultsQoL data was extracted from 17 articles (14 datasets), encompassing 659 patients (102 EPP, 432 P/D); the available evidence was of low quality. While two studies directly compared QoL between the two surgical procedures, additional data was available from one arm of two RCTs, as the RCTs were not comparing EPP and P/D. The remaining data was reported from observational studies. While QoL was still compromised 6 months following surgery, from the limited and low quality data available it would appear that P/D patients had better QoL than EPP patients across all measures. Physical function, social function and global health were better at follow-up for P/D than for EPP, while other indicators such as pain and cough were similar. Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were reported in one study only, and were higher at follow-up for P/D compared to EPP.ConclusionsAlthough the existing evidence is limited and of low quality, it suggests that P/D patients have better QoL than EPP patients following surgery. QoL outcomes should be factored into the choice of surgical procedure for MPM patients, and the possible effects on lung function and QoL should be discussed with patients when presenting surgical treatment options.

Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma.

We evaluated postoperative mortality and complications after extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) to better understand their effectiveness in malignant pleural mesothelioma (MPM). A meta-analysis was done to evaluate 30-day mortality and postoperative complications. In addition, in-patients data of 500 eligible patients with MPM who underwent EPP or P/D was extracted from the New York Statewide Planning and Research Cooperative System (SPARCS). Multivariate analyses and propensity matching were used to compare in-hospital mortality and postoperative complications in EPP vs P/D. The meta-analysis showed a statistically significant difference in 30-day mortality (5% [95% CI: 4-6] vs P/D 2% [95% CI: 1-3]), proportion of complications (46% [95% CI: 36-56] vs 24% [95% CI: 15-34]) and postoperative arrhythmias (20% [95% CI: 12-31] vs 5% [95% CI: 2-8]) for EPP vs P/D. In-hospital mortality (OR adj : 2.6; 95% CI: 0.86-7.75) and postoperative complications (OR adj : 1.1; 95% CI: 0.68-1.86) were not different in EPP compared with P/D while supraventricular arrhythmia was significantly more frequent after EPP vs P/D (OR adj : 5.2; 95% CI: 2.34-11.33). Postoperative mortality, postoperative complications, and particularly supraventricular arrhythmia are less frequent after P/D vs EPP. P/D, a less invasive surgery, may provide a better option when technically feasible for patients with MPM.

Mésothéliome pleural malin : place de la chirurgie

Malignant pleural mesothelioma (MPM) is a rare and highly aggressive disease, whose incidence is increasing. Asbestos is the primary causal agent. Knowledge about MPM has evolved. Thoracoscopy is essential for diagnosis of MPM. It allows performing pleural biopsies, to study the extent of the disease and to relieve dyspnea. The pathological diagnosis is also better codified with immunohistochemistry and with analysis by expert of Mesopath group. Curative surgical treatments are pleurectomy decortication and extended pneumonectomy in combination with chemotherapy and/or radiotherapy. Those heavy treatments improve survival in highly selected patients. For the other patients, supportive measures will be considered to reduce pain and dyspnea. Radical surgical treatment is only offered in therapeutic trials or multimodal treatment. Its place is not formally established. New therapies associated to surgical treatment are being studied. Surgical management of MPM has to be operated in specialized teams where the survival benefit and quality of life is discussed case by case.

MA12.02 Quality of Life Following Pleurectomy Decortication and Extrapleural Pneumonectomy for Pleural Malignant Mesothelioma

MA12.02 Quality of Life Following Pleurectomy Decortication and Extrapleural Pneumonectomy for Pleural Malignant Mesothelioma

A randomized phase II study of pleurectomy/decortication preceded or followed by (neo-)adjuvant chemotherapy in patients with early stage malignant pleural mesothelioma (EORTC 1205).

Radical multimodality treatment for malignant pleural mesothelioma (MPM) is controversial, with intense debate (but lack of data) about which surgical procedure to perform [extrapleural pneumonectomy (EPP) or pleurectomy/decortication (PD)], if any. In order to perform a randomized comparison, the most optimal sequence of surgery and chemotherapy should be determined. EORTC 1205 is a clinical trial randomizing between upfront surgery, followed by chemotherapy (cisplatin plus pemetrexed) and deferred surgery, following neoadjuvant chemotherapy in early stage (T1-3 N0-2 M0) MPM (irrespective of histological subtype). The surgical procedure performed is (extended) pleurectomy/decortication (e-PD), which is promoted as an alternative for EPP, but lacks standardization. Primary outcome parameter is successful completion of multimodality treatment; secondary outcome parameters are surgical quality parameters (in order to standardize the procedure), progression free survival (PFS) and overall survival (OS), treatment-failure free survival, operative morbidity and mortality, toxicity and safety.

GR01.03 Surgical Oncology

In this section we will address the controversial areas of surgical management in the more advanced stages of thymoma. Using case-based discussion we will debate the following clinical scenarios: Stage III Thymic tumours ( with invasion of great vessels) Is there a role for primary surgical debulking leaving an intentional R2 resection? There is little survival evidence to support intentional debulking but such procedures may reduce the dose and extent of radiotherapy subsequently required and therefore the associated morbidity [1]. However, there is a lack of supportive evidence for debulking surgery in thymic carcinoma. [2,3] Should primary treatment be chemoradiotherapy followed by consolidation surgery? Induction therapy is feasible in locally advanced thymic tumours and has been reported to achieve around a 50% partial response. A complete pathological response has not been seen but such treatment can facilitate a high rate (over75%) of R0 resection.[4] Stage IVa Thymic tumours – pleural/pericardial deposits Is there a role for radical surgery? The International Thymic Malignancies Interest Group have recommended that in locally-advanced Stage IVa patients with pleural involvement, major pleural resections, including pleurectomy/decortication or extrapleural pneumonectomy are indicated, provided a complete resection of the pleural deposits is anticipated, usually in a multidisciplinary setting [5] Should this be extrapleural pneumonectomy or thymectomy and extended pleurectomy/decortication? As in other disease, extrapleural pneumonectomy (EPP) is associated with a high 30 day mortality of up to 17% (6). Providing a complete resection can be achieved there is no difference between EPP and extended pleurectomy decortication (EPD) (7] and median survival may exceed 4 years. The contribution of occult nodal metastases must be recognized and radical resection must include lymph node dissection. Stage migration due to lymph node metastases, WHO-classification type C, and T3/4-status are associated with inferior survival but extended surgery has been found to be the only independent significant prognosticator in multivariate analysis [8,9]. Which surgical incision is best? Radical resections can be facilitated by extended approaches which are well tolerated and adequate exposure is necessary to ensure a complete resection Recurrent thymic tumour – after previous resection Is there evidence that extending local control prolongs overall survival over systemic therapy alone? Survival is acceptable and superior to non surgical treatment if complete resection of recurrence is achieved. There is no evidence to support debulking of recurrent thymoma [10] A significant poorer prognosis is associated with multiple versus single relapses, Masaoka stage III primary tumour versus Masaoka stage I-II primary tumour, distant versus loco-regional relapses and B3 histotype versus other. On multivariate analysis, completeness of resection, number of metastases, Masaoka stage of primary tumour and site of relapse were identified as the only independent predictors of prognosis [10] The relative rarity of thymic neoplasms has contributed to the lack of high grade evidence from randomized controlled trials of large numbers of patients. Most supportive evidence for radical surgery in advanced thymic malignancies has therefore been provided by relatively small selected case series. However, the formation of larger collaborative groups with cumulative databases has provided more robust support for extended surgical procedures that many have avoided previously. The superiority of resection as part of multimodality treatment over non-surgical treatment alone seems to be justified provided high quality surgical standards are maintained.

P2.06-03 Can We Predict Pathological Nodal Positivity in Malignant Pleural Mesothelioma from Preoperative Clinical Variables?

The associated morbidity from radical surgery implies that it should only be offered to those with the best prognosis. The prognosis following radical surgery for mesothelioma is significantly influenced by the presence of pathological nodal metastases. However, the prediction of nodal positivity is inaccurate and complicated. This can be attributed to the unique lymphatic drainage pattern in which many nodal groups (internal mammary, intercostal) cannot be biopsied preoperatively. Previous studies have correlated preclinical variables with poor prognosis (Pass, J Thorac Oncol.2014;9:856-64). We have correlated clinical variables known to be associated with overall prognosis in mesothelioma with the pathological findings of systematic nodal dissection at thoracotomy and pleurectomy/decortication. The variables analysed: patient demographics, Haemoglobin and CRP, T and N stage on preoperative CT scan, duration of symptoms of weight loss and chest pain and cell type on preoperative biopsy. Data were summarised as median (range), mean (SD) and subject to Chi-squared test for the categorical data and Mann-Whitney Test for the numeric data and to regression analysis. 32 patients(25males:7females)underwent extended pleurectomy decortication with intraoperative systematic nodal dissection. On pathologic diagnosis post-resection, 20(62%) patients were diagnosed with nodal metastasis. On univariate analysis, only age and CRP was statistically significant (p=0.049,respectively 0.05). The remaining variables did not achieve statistical significance. There were statistical trends suggesting that nodal positivity was more likely in the younger males with a lower Haemoglobin and a raised CRP. CT correctly predicted positive node status in 30% of cases and negative node status in 80% of cases. Nodal positivity in patients suitable for EPD cannot be reliably predicted by CT but can be inferred from certain clinical variables. Future work in a larger population is required to identify a definitive pre-operative model. This will allow for better selection of patients for primary surgical intervention or alternatively for induction chemotherapy.

Poor Prognostic Factors in Patients with Malignant Pleural Mesothelioma Classified as Pathological Stage IB According to the Eighth Edition TNM Classification.

The change in TNM classification of malignant pleural mesothelioma (MPM) between the seventh and eighth edition classifications has resulted in the downstaging of many advanced-stage patients into pathological stage IB. Many mesotheliomas without lymph node metastasis have been classified as stage IB in the eighth edition classification. Stage IB mesotheliomas comprised a heterogeneous group with different prognosis. It is necessary to clarify the prognostic factors in this group. Between September 2009 and August 2016, a total of 89 patients with MPM underwent curative intent surgery [pleurectomy decortication n=57 (64.1%), extrapleural pneumonectomy n=32 (35.9%)] at our institution. Of these, 40 were reclassified as stage IB according to the eighth edition TNM classification. Independent unfavorable prognostic factors were identified by univariate analyses using the log-rank test and Cox proportional hazards regression models. Three independent significant factors were identified that indicated an unfavorable prognosis: a nonepithelioid subtype, lymphovascular invasion, and preoperative forced expiratory volume in 1s (FEV1) <2000ml. Patients with no, one, and two of these risk factors showed 3-year overall survival probabilities of 94.7, 62.5, and 0%, respectively. The 3-year survival of patients with one factor did not differ significantly from that of patients with stage III MPM, whereas that of patients with two factors was significantly shorter (p=0.015). Independent poor prognostic factors for patients with stage IB MPM patients, allowing subgroups with poorer and more favorable prognoses to be identified. This should help personalize decisions on adjuvant chemotherapy.

Macroscopic complete resection is not associated with improved survival in patients with malignant pleural mesothelioma

ObjectiveMacroscopic complete resection (MCR) is the recommended surgical strategy in malignant pleural mesothelioma. Our objective was to analyze whether MCR influences survival in malignant pleural mesothelioma. MethodsBetween 2002 and 2016, 154 patients underwent pleurectomy decortication (n = 90), extrapleural pneumonectomy (n = 42), or exploratory/diagnostic procedures (n = 22) in a single institution. Patient data were recorded in a prospective database. Patients who underwent surgical resection (n = 132) were analyzed according to MCR as a whole group and after propensity score matching based on gender, age, histology, clinical T and N status, adjuvant chemotherapy, and trimodality treatment. Kaplan-Meier survival and univariate and multivariate analyses were performed. ResultsMedian age was 56 years (range, 26 to 80 years) and 62 were women. One hundred ten had epithelioid histology. MCR was achieved in 75 patients (49%). In-hospital mortality was seen in 7 patients (4.5%). Preoperative chemotherapy was applied in 32 patients. One hundred thirty-three patients underwent adjuvant treatment (45 had chemoradiation). Mean follow-up was 21 ± 19 months. Overall median survival, 2-year, and 5-year survivals were 18.1 months, 36%, and 16%, respectively. There was no difference in median survival between patients who underwent MCR (21.4 months) and who did not (16.3 months) (P = .6). Following propensity score matching (23 patients in each group), median survivals were similar (13.3 vs 14.2 months; P = .63). ConclusionsMCR was not associated with improved survival in malignant pleural mesothelioma. We need to clearly define MCR and identify subgroups of patients who would benefit from this principle because minimal versus extensive and location of gross residual disease may have different influences on survival.

Decade Experience in Pleurectomy and Lung Decortications for Chronic Empyema Thoracis

Background: Chronic empyema thoracis is a debilitating illness with high morbidity and mortality, and is seen among all age groups in Nigeria. Objective: To review all cases of chronic empyema thoracis treated by pleurectomy and lung decortication and highlight the indications, challenges and the outcome. Materials and Method: In a 10-year period spanning 2007-2016, 90 patients with chronic empyema thoracis were admitted and managed in our institution. A retrospective study of 36 patients who underwent surgery was performed. Results: Ten patients (27.80%) out of 36 patients had unsuccessful one month closed chest tube drainage (CTTD). Six patients (16.67%) were referred from peripheral hospitals as chronic empyema thoracis that had failed CTTD. The remainder, 20 (55.60%) were diagnosed as chronic empyema thoracis de novo. Conclusion: Chronic empyema thoracis is a very difficult disease to manage especially in developing countries like ours, where patients present very late and the requisite facilities are inadequate.

186 - Patient experience of extended pleurectomy decortication (EPD) and chemotherapy in the MARS 2 feasibility trial: findings from a longitudinal qualitative sub-study

186 - Patient experience of extended pleurectomy decortication (EPD) and chemotherapy in the MARS 2 feasibility trial: findings from a longitudinal qualitative sub-study

Induction or adjuvant chemotherapy for radical multimodality therapy

The use of radical surgery, with either extrapleural pneumonectomy (EPP) or extended pleurectomy decortication (EPD), as part of multimodality treatment in malignant pleural mesothelioma (MPM) has been shown to prolong survival outcomes. The platinum/pemetrexed doublet is used as standard first line chemotherapy as it is the only treatment proven in a randomized trial setting to give a survival advantage. It is unclear as to the optimal timing of chemotherapy, either in the neoadjuvant or immediate adjuvant setting. Some oncologists also favour reserving this standard therapy for the time at which the disease progresses following debulking surgery. Recently published guidelines from the American Society of Clinical Oncology (ASCO) recommend the use of chemotherapy as part of multimodality treatment, but do not stipulate at which point in the treatment regime this should be given. Further research is required to determine the optimal timing of chemotherapy in the context of the multimodality treatment of MPM.

Review of malignant pleural mesothelioma survival after talc pleurodesis or surgery.

Malignant pleural mesothelioma (MPM) is an aggressive tumor and the prognosis is still dismal despite the various proposed multimodal treatment plans. Currently, new palliative treatments, such as talc pleurodesis, are being explored besides traditional surgery. This review reports survival rates after talc pleurodesis in comparison to surgery in patients with malignant pleural mesothelioma. A systematic literature search yielded 49 articles eligible for this review. The mean survival in the talc pleurodesis group was 14 months compared to 17 and 24 months for the pleurectomy decortication (P/D) group and extrapleural pneumonectomy (EPP) group, respectively. Few studies reported on the 1-, 2-year overall survival for the talc pleurodesis group and the results were very heterogeneous. The pooled 1-year overall survival for the P/D and EPP groups were 55% [credibility limits (CL): 21-87%] and 67% (CL: 3-89%), the pooled 2-year overall survival were 32% (CL: 8-63%) and 36% (CL: 8-54%), respectively. The pooled 1- and 2-year survival for surgery independently from the type of surgery were 62% (CL: 38-84%) and 34% (CL: 16-54%). There was significant heterogeneity in all the analyses. This review shows that there is limited research on the survival rate after talc pleurodesis compared to surgery in the treatment of malignant pleural mesothelioma. A comparison study is necessary to accurately assess the best way to treat MPM patients, including assessment of the quality of life after treatment as an outcome measure.

OA 02.07 Surgical Selection in Pleurectomy Decortication for Mesothelioma – an Overview from Screening and Selection from MARS 2 Pilot

Encouraging survival has been reported with pleurectomy decortication (PD) for malignant pleural mesothelioma (MPM) in several surgical case series. However, doubts remain over the degree of selection bias that constitutes the final composition of these series which therefore lead to questions surrounding the validity of the reported outcomes. We have reviewed our initial experience in the MARS 2 study to analyze this surgical selection process in more detail.

Extended pleurectomy decortication for malignant pleural mesothelioma in the elderly: the need for an inclusive yet selective approach.

The median age at diagnosis of patients with pleural mesothelioma in the UK is 73 years. Recent series have shown the feasibility of extended pleurectomy decortication in the elderly, but with continuing debate about the efficacy of this treatment, we reviewed our experience to identify more detailed selection criteria. We reviewed prospectively collected data on all patients from 1999 to 2016 undergoing extended pleurectomy decortication. We compared clinical and pathological outcomes and survival data from patients 70 years and older (≥70 years) with those younger than 70 years (<70 years). Eighty-two of the 300 (27.3%) patients were ≥70 years of age at the time of surgery. More patients in the elderly group required intensive care postoperatively (6.2 vs 16.7%, P = 0.01) and developed atrial fibrillation (14.4 vs 24.4%, P = 0.05). There was no intergroup difference in length of hospital stay or in in-hospital, 30-day or 90-day mortality. Elderly patients were less likely to receive neoadjuvant (<70 years 21.2%, ≥70 years 11.0%; P = 0.045) or adjuvant chemotherapy (<70 years 45.4%, ≥70 years 29.3%; P = 0.04). Median overall survival was similar: <70 years 14.0 months, ≥70 years 10.3 months; P = 0.29. However, in node-positive patients, survival was poorer in the elderly (13.0 vs 9.1 months, P = 0.05), particularly in those with non-epithelioid tumours (3.8 vs 6.7 months, P = 0.04). On multivariable analysis, age was not a significant prognostic factor, although lack of adjuvant therapy (P = 0.001) and admission to the intensive care unit (P < 0.001) remained poor prognostic factors. Although age in isolation should not be an exclusion criterion for extended pleurectomy decortication for mesothelioma, in the elderly, a more rigorous preoperative evaluation of nodal disease and an additional assessment of fitness for adjuvant chemotherapy are recommended.

Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases.

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.

The impact of surgical approach on quality of life for pleural malignant mesothelioma.

A comprehensive review of quality of life (QoL) after surgery for malignant pleural mesothelioma (MPM) was conducted to assess differences between pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP). Original research studies on quality of life after mesothelioma surgery were identified through June 2016; 15 articles and 12 distinct datasets, for a total of 523 patients, were retrieved. QoL data was available for 102 patients treated with EPP and 296 with P/D. Two studies directly compared QoL outcomes between the two techniques. Symptoms, lung function parameters, and physical and social functioning were still compromised 6 months following surgery. However, P/D patients fared better than EPP patients across QoL measures. Quality of life is generally better for patients undergoing P/D compared to EPP, for an extended period following surgery. Given the need for multimodality therapy and the aggressive nature of MPM, QoL outcomes should be strongly considered when recommending type of surgery for patients with this disease.

Effect of FAK inhibitor defactinib on tumor immune changes and tumor reductions in a phase II window of opportunity study in malignant pleural mesothelioma (MPM).

8555 Background: Defactinib is an oral Focal Adhesion Kinase (FAK) inhibitor with preclinical activity in MPM. We assessed responses to defactinib treatment prior to planned surgical resection in naive patients with MPM. Methods: Three cohorts of 10 participants each received defactinib 400mg BID for 12, 35 and 21 days. Pre- and post-treatment blood, tumor biopsies and imaging were obtained for biomarker, immune cell and tumor response (modified RECIST, Tumor volume and SUV max) assessment. Toxicity was monitored for 30 days post treatment. Results: Between 12/2013 and 12/2017, 31 participants were registered at our center; 1 withdrew prior to intervention. Among 30 treated, 24 (80%) were male; median age 70 (47-83) years; surgery was EPP 7%, complete pleurectomy decortication (PD) 10%, extended PD 60%, partial PD 10%, unresectable 13%; MPM subtype was epithelioid 67%, biphasic 17%, sarcomatoid 17%. Expected complications of FAK inhibition, diagnostic/staging/operative procedures occurred in 83% (grade 1, 30%; grade 2, 43%; grade 3, 10%). Unexpected adverse events occurred in 77% (grade 1, 63%; grade 2, 20%; grade 3, 17% [wound-infection, prolonged QT interval, and hyperglycemia in 3% each; increased INR in 7%]; grade 5, 7% [due to progressive disease in 3%, intraoperative anaphylactoid reaction unrelated to the drug in 3%]). Objective partial response was observed in 13%, stable disease in 67%, progression in 17%. Tumor volume decreased 3-72% in 47% patients and increased 1-82% in 53%. SUV max decreased 3-69% in 50% and increased 1-61% in 50%. Biological correlates of treatment included target inhibition (75% pFAK reduction); tumor immune microenvironment changes: increased naïve (CD45RA+PD-1+CD69+) CD4 and CD8 T cells, reduced myeloid and Treg immuno-suppressive cells, reduced exhausted T cells (PD-1+CD69+), reduced peripheral MDSCs; and histological subtype change (pleomorphic or biphasic to epithelioid) in 13% of cases. Conclusions: Brief preoperative defactinib exposure was well tolerated, did not alter resectability or mortality compared to prior series, and showed evidence of therapeutic and immunomodulatory effects. Clinical trial information: NCT02004028.

Pleurectomy-decortication in malignant pleural mesothelioma: are different surgical techniques associated with different outcomes? Results from a multicentre study.

The potential benefit of surgery for malignant pleural mesothelioma (MPM), especially concerning pleurectomy/decortication (P/D), is unclear from the literature. The aim of this study was to evaluate the outcome after multimodality treatment of MPM involving different types of P/D and to analyse the prognostic factors. We reviewed 314 patients affected by MPM who were operated on in 11 Italian centres from 1 January 2007 to 11 October 2014. The characteristics of the population were male/female ratio: 3.7/1, and median age at operation was 67.8 years. The epithelioid histotype was observed in 79.9% of patients; neoadjuvant chemotherapy was given to 57% of patients and Stage III disease was found following a pathological analysis in 62.3% of cases. A total of 162 (51.6%) patients underwent extended P/D (EP/D); 115 (36.6%) patients had P/D and 37 (11.8%) received only a partial pleurectomy. Adjuvant radiotherapy was delivered in 39.2% of patients. Median overall survival time after surgery was 23.0 [95% confidence interval (CI): 19.6-29.1] months. On multivariable (Cox) analysis, pathological Stage III-IV [ P = 0.004, hazard ratio (HR):1.34; 95% CI: 1.09-1.64], EP/D and P/D ( P = 0.006, HR for EP/D: 0.46; 95% CI: 0.29-0.74; HR for P/D: 0.52; 95% CI: 0.31-0.87), left-sided disease ( P = 0.01, HR: 1.52; 95% CI: 1.09-2.12) and pathological status T4 ( P = 0.0003, HR: 1.38; 95% CI: 1.14-1.66) were found to be independent significant predictors of overall survival. Whether the P/D is extended or not, it shows similarly good outcomes in terms of early results and survival rate. In contrast, a partial pleurectomy, which leaves gross tumour behind, has no impact on survival.

Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma

ObjectivesNo clear evidence of which surgical procedure should be performed for early stage mesothelioma is available to date. We analyzed our 10-year experience in the treatment of early stage mesothelioma with surgery and Hyperthermic IntraTHOracic Chemotherapy. MethodsWe retrospectively analyzed all cases of histologically proven epithelioid or biphasic IMIG stage I and II mesothelioma that we operated between 2005 and 2014. We performed an open pleurectomy and partial decortication of any visible lesion on the visceral pleura in all cases and both diaphragm and pericardium were always spared; Hyperthermic IntraTHOracic Chemotherapy was ran using Cisplatin 80 mg/m2 and Doxorubicin 25 mg/m2 at a target temperature of 42.5 °C for 60 min. ResultsWe operated on 26 patients (23 male and 3 female); epithelioid tumor was diagnosed in 23 cases. Twelve patients were in IMIG stage I and 14 in IMIG stage II; median overall survival for all patients, stage I and II were 35.6, 46 and 23 months respectively and disease free survival was 18, 18 and 16 months respectively. Our results for stage I were better than those reported in literature and were similar for stage II. We observe no 30- and 90- mortality and the rate of severe complication (all CTCAE stage 3) were 30%; the median postoperative stay was 7.5 days. ConclusionsOur lung sparing approach for the treatment of pleural mesothelioma in early stages allows promising long term outcomes with a complete sparing of pulmonary and diaphragmatic function. Larger studies are needed to confirm our good results.