Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma

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Abstract

Aims

Malignant mesothelioma is increasing in incidence and no current therapy significantly prolongs survival. Previous surgical strategies involved high-risk open procedures without achieving histologically clear resection margins. We present the results of VATS debulking pleurectomy-decortication in advanced disease.

Methods

A consecutive series of patients with suspected malignant mesothelioma underwent thoracoscopic assessment to determine the feasibility of decortication, where this was not possible a biopsy alone was taken. Post-operative radiotherapy was administered to port sites, but no other adjuvant therapy was given. The two groups (biopsy only and pleurectomy-decortication) were composed of patients with histologically confirmed mesothelioma [28 and 51 patients, respectively]. The primary endpoint was comparison of actuarial patient survival. Secondary endpoints included post-operative air leak and duration of hospital stay.

Results

The overall actuarial survival was 288 days and 67% of patients had died at the time of data analysis. The groups were matched for patient and tumour-related characteristics including age (66, 64 years, p=0.39) and tumour stage (median IMIG stage 3 [IQR 2–3] both groups, p=0.54). The biopsy only group had fewer air leaks (57, 84%, p=0.01) and a shorter hospital stay (4, 8 days, p=0.03). However, the pleurectomy-decortication group had favourable actuarial survival relative to the biopsy only group (416, 127 days, p<0.001). Multivariate analysis showed early stage (p<0.001), absence of pre-operative fever (p=0.03) and pleurectomy-decortication (p<0.001) as independent predictors of survival.

Conclusion

VATS pleurectomy-decortication is feasible in the majority of cases and independently improves survival for patients with advanced malignant mesothelioma.

Introduction

Malignant mesothelioma is the commonest primary tumour of the pleura. It is uniformly fatal and increasing in incidence.1 Numerous treatment options have been proposed and include surgery, radiotherapy, chemotherapy, immunotherapy, gene therapy, photodynamic therapy, and multimodality combinations. Unfortunately, no surgical or oncological strategy has significantly improved the poor prognosis associated with this disease.2

Potentially therapeutic surgical options such as extrapleural pneumonectomy are associated with significant operative mortality and morbidity rates, only suitable for selected patients and probably only prolong survival in a favourable subset when combined with adjuvant therapies.3, 4, 5 Open debulking surgical techniques such as pleurectomy-decortication have been combined with chemotherapy to produce acceptable survival in patients with more advanced disease.6

In order to ascertain, the impact of thoracoscopic debulking surgery on survival, we prospectively studied a series of patients with advanced malignant mesothelioma who underwent minimal access pleurectomy-decortication at our institution.

Section snippets

Patients and methods

The primary objective of this study was to ascertain the impact of thoracoscopic pleurectomy-decortication on survival in patients with advanced malignant mesothelioma compared with a matched group of patients who underwent biopsy alone.

Ethical approval for this study was obtained from the Local Research Ethics Committee, and a prospective registry of patients with suspected malignant pleural mesothelioma was created in 1996 by a single cardiothoracic surgeon (AJR). Cases that were confirmed on

Results

From 1996 to 2001, there were 79 cases of histologically confirmed malignant mesothelioma (there were no known failures of diagnosis). Of these, 71 were male, and the mean age (SD) of the cohort was 64 (9) years. The histological diagnosis was epithelial malignant mesothelioma in 48 patients, sarcomatoid in three and mixed cellularity in 28.

Pleurectomy-decortication was achieved in 51 patients, and biopsy only in 28. Both groups were well matched for age, tumour subtype and stage. However, more

Discussion

Surgery for malignant mesothelioma has ranged from extrapleural pneumonectomy (EPP) to incision biopsy alone. EPP enables the use of high dose hemithoracic radiotherapy, which together have been shown to reduce local recurrence and prolong survival for early stage tumours.9 However, early reports of EPP showed poor results with high hospital mortality and little prognostic benefit amongst survivors.3, 10 More recently, this operation has been combined with other treatment modalities, even then,

Conclusion

For patients who are suitable for VATS pleurectomy-decortication, this minimal access approach has a low operative mortality and acceptable morbidity. When used as unimodality therapy, this procedure independently improves survival for patients with advanced malignant mesothelioma.

We believe that this technique is likely to be an important palliative strategy and is applicable to the majority of patients rather than highly selected subgroups.

References (14)

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