Pleurectomy/Decortication is Superior to Extrapleural Pneumonectomy in the Multimodality Management of Patients with Malignant Pleural Mesothelioma

Abstract

To compare the outcomes of two different multimodality regimens involving neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant radiotherapy versus pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy in patients with malignant pleural mesothelioma. Methods: Nonrandomized prospective study of patients treated by multimodality therapy and operated on between January 2004 and June 2011. Second-line treatments were administered when appropriate. Survival and prognostic factors were analyzed by the Kaplan Meier method, log rank test, and Cox regression analysis. Results: Twenty-five consecutive patients received neoadjuvant chemotherapy, 22 underwent EPP, and 17 received adjuvant radiotherapy. over the same period, 54 consecutive patients underwent P/D and hyperthermic pleural lavage and received prophylactic radiotherapy and adjuvant chemotherapy. The 30-day mortality rate was 4.5% in the EPP group and nil in the P/D group. Fifteen patients (68%) in the EPP group and 15 (27.7%) in the P/D group experienced complications. There were no differences between the EPP and P/D groups for age, sex, histology, pathologic stage, and nodal status. Trimodality therapy was completed by 68% of the patients in the EPP group and 100% in the P/D group. Survival was significantly better in the P/D group: median survival was 23 months versus 12.8 months, 2-year survival was 49% versus 18.2 %, and 5-year survival was 30.1% versus 9%, respectively (p = 0.004). At multivariate analysis, epithelioid histology, P/D, and completeness of resection were independent prognostic factors. Conclusions: In our experience, P/D, hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy were superior to neoadjuvant chemotherapy, EPP, and adjuvant radiotherapy.

Multimodal management of malignant pleural mesothelioma: where are we today?

“…As mentioned previously, the addition of hyperthermic pleural lavage with povidone-iodine is feasible but its effect on the rate and time to local recurrence remains unproven [54,64].…”

“…Another pivotal, prospective but nonrandomised study compared EPP to P/D performed during a 7-year period [54]. In the EPP group, trimodal therapy was given; 25 patients underwent induction chemotherapy, 22 had EPP and in 17 patients, 54 Gy post-operative radiotherapy was administered.…”

Validation of EORTC and CALGB prognostic models in surgical patients submitted to diagnostic, palliative or curative surgery for malignant pleural mesothelioma

“…This has been evidenced by a meta-analysis with a consistent number of patients treated with P/D and EPP, concluding that P/D should be preferred to EPP whenever feasible (11). The debate on whether P/D is superior to EPP or vice-versa is still on going but with a growing recognition that P/D offers a good compromise between long-term survival and postoperative quality of life if compared to EPP (11)(12)(13)(14)(15)(16)(17)(18).…”

Pleurectomy and decortication

“…A literature review evaluating reports in the last 10 years of outcomes after pleurectomy decortication demonstrates a median survival between 10 and 25 months (Table 1) (2,5,9,12,(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). Thirty-day mortality was between 0.0-6.8% across all studies.…”

“…Previous studies have shown that volume of disease correlates with overall survival (7). In regards to mesothelioma, however, the literature varies regarding what constitutes an adequate or maximum cytoreduction (8)(9)(10)(11)(12). Although there exists a completeness of cytoreduction score (CCS) for peritoneal malignancies, there currently does not exist a CCS for mesothelioma.…”