1
|
Wolf AS, Eisele M, Giroux DJ, Gill R, Nowak AK, Bille A, Rice D, Ripley RT, Opitz I, Galateau-Salle F, Hasegawa S, Kindler HL, Pass HI, Rusch VW. The International Association for the Study of Lung Cancer Pleural Mesothelioma Staging Project: Expanded Database to Inform Revisions in the Ninth Edition of the TNM Classification of Pleural Mesothelioma. J Thorac Oncol 2024:S1556-0864(24)00059-5. [PMID: 38309456 DOI: 10.1016/j.jtho.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/22/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
The International Association for the Study of Lung Cancer collaborated with the International Mesothelioma Interest Group to propose the first TNM stage classification system for diffuse pleural mesothelioma in 1995, accepted by the Union for International Cancer Control and the American Joint Committee on Cancer for the sixth and seventh edition stage classification manuals. The International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee Mesothelioma Domain developed and analyzed an international registry of patients with pleural mesothelioma and updated TNM descriptors for the eighth edition of the stage classification system. To inform revisions for the forthcoming ninth edition of the TNM stage classification system, data submission was solicited for patients diagnosed between 2013 and 2022 with expanded data elements on the basis of the first project's exploratory analyses, including pleural thickness measurements, updated surgical nomenclature, and molecular markers. The resulting database consisted of a total of 3598 analyzable cases from Europe, Australia, Asia, North America, and South America, with a median age of 71 years (range: 18-99 y), 2775 (77.1%) of whom were men. With only 1310 patients (36.4%) undergoing curative-intent operations, this iteration of the database includes far more patients treated nonsurgically compared with prior. Four separate manuscripts on T, N, M, and stage groupings submitted to this journal will summarize analyses of these data and will serve collectively as the primary source of the proposed changes to the upcoming ninth edition of the pleural mesothelioma stage classification system.
Collapse
Affiliation(s)
- Andrea S Wolf
- Department of Thoracic Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Megan Eisele
- Cancer Research And Biostatistics, Seattle, Washington
| | | | - Ritu Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anna K Nowak
- Medical School of the University of Western Australia, Crawley, Western Australia, Australia
| | - Andrea Bille
- Department of Thoracic Surgery, Guy's Hospital, London, United Kingdom
| | - David Rice
- Department of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Robert T Ripley
- Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Seiki Hasegawa
- Departments of Thoracic Surgery and Thoracic Oncology, Hyogo College of Medicine, Hyogo, Japan
| | - Hedy L Kindler
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Harvey I Pass
- Department of Cardiothoracic Surgery, NYU-Langone Medical Center, New York, New York
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
2
|
Orlandi R, Leuzzi G, Rolli L, Ferrari M, Stanzi A, Valsecchi C, Pastorino U. Long-Term Survival Analysis of Pleural Mesothelioma Patients Undergoing Surgery: Brief Report From a Tertiary Referral Centre. Clin Lung Cancer 2024; 25:e5-e10. [PMID: 37980239 DOI: 10.1016/j.cllc.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES to date, no consensus has been reached on the surgical gold-standard in pleural mesothelioma (PM). We retrospectively reviewed our experience as a tertiary referral centre, to compare short- and long-term survival of PM patients undergoing different types of surgery. METHODS in retrospective, observational, single-centre study, we analysed all the patients histologically diagnosed with PM undergoing surgical procedures with palliative or curative intent at IRCCS Istituto Nazionale dei Tumori of Milan, Italy, from January 2003 to December 2020. The primary study endpoint was 10-year overall survival (OS) in three different types of resections: extra-pleural-pneumonectomy (EPP), pleurectomy/decortication (P/D), partial-pleurectomy/pleural-biopsy (PP/B). Secondary endpoints were postoperative hospital stay and postoperative 30-day and 90-day mortality rates. The survival function was estimated using Kaplan-Meier, and the Log-rank test was used for testing differences. Univariable and Multivariable Cox regression models were implemented to estimate Hazard Ratio (HR) for all variables of interest. RESULTS 243 consecutive patients were enrolled, EPP was performed in 49 (20.2%), P/D in 58 (23.8%), PP/B in 136 (56.0%) patients. The median follow-up time was 19.8 months. 10-year OS was significantly better for P/D group (16%, Log-Rank test p<0.0001) compared to PP/B (1.8%) and EPP (0%). No statistically significant differences were found among the 3 surgical groups in 30- and 90-day mortality rates. At multivariable analysis, gender (male, HR=1.58), type of resection (P/D, HR=0.55) and surgery date (recent years, HR=0.61) were found to be independent prognostic factors for OS. CONCLUSIONS in PM, lung-sparing curative approach (e.g. P/D) should be preferred in highly selected patients and in highly experienced centres, whenever appropriate. Anyway, when P/D is not indicated, adopting palliative/conservative management (e.g. PP/B) could ensure comparable results as extremely aggressive surgeries (e.g. EPP). The aim of surgery in PM should not be reaching complete resection, but rather accomplishing significant resection allowing to complete the multimodality treatment in highly selected patients in experienced centers.
Collapse
Affiliation(s)
- Riccardo Orlandi
- Department of Thoracic Surgery, University of Milan, Milan, Italy.
| | - Giovanni Leuzzi
- Division of Thoracic Surgery, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Luigi Rolli
- Division of Thoracic Surgery, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Michele Ferrari
- Division of Thoracic Surgery, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Alessia Stanzi
- Division of Thoracic Surgery, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Camilla Valsecchi
- Division of Statistics, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Ugo Pastorino
- Division of Thoracic Surgery, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| |
Collapse
|
3
|
Wolf AS, Rosenthal A, Giroux DJ, Nowak AK, Bille A, de Perrot M, Kindler HL, Rice D, Opitz I, Rusch VW, Pass HI. The International Association for the Study of Lung Cancer Pleural Mesothelioma Staging Project: Updated Modeling of Prognostic Factors in Pleural Mesothelioma. J Thorac Oncol 2023; 18:1689-1702. [PMID: 37567386 DOI: 10.1016/j.jtho.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION The International Association for the Study of Lung Cancer developed an international pleural mesothelioma database to improve staging. Data entered from 1995 to 2009 (training data set) were analyzed previously to evaluate supplemental prognostic factors. We evaluated these factors with new clinical data to determine whether the previous models could be improved. METHODS Patients entered into the database from 2009 to 2019 (validation cohort) were assessed for the association between previous prognosticators and overall survival using Cox proportional hazards regression with bidirectional stepwise selection. Additional variables were analyzed and models were compared using Harrell's C-index. RESULTS The training data set included 3101 patients and the validation cohort, 1733 patients. For the multivariable pathologic staging model applied to the training cohort, C-index was 0.68 (95% confidence interval [CI]: 0.656-0.705). For the validation data set (n = 497), C-index was 0.650 (95% CI: 0.614-0.685), and pathologic stage, histologic diagnosis, sex, adjuvant therapy, and platelet count were independently associated with survival. Adding anemia to the model increased the C-index to 0.652 (95% CI: 0.618-0.686). A basic presentation model including all parameters before staging yielded a C-index of 0.668 (95% CI: 0.641-0.695). In comparison, the European Organization for Research and Treatment of Cancer model yielded C-indices of 0.550 (95% CI: 0.511-0.589) and 0.577 (95% CI: 0.550-0.604) for pathologic staging and presentation models, respectively. CONCLUSIONS Although significant predictors differed slightly, the International Association for the Study of Lung Cancer training model performed well in the validation set and better than the model of the European Organization for Research and Treatment of Cancer. International collaboration is critical to improve outcomes in this rare disease.
Collapse
Affiliation(s)
- Andrea S Wolf
- Department of Thoracic Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York.
| | | | | | - Anna K Nowak
- Medical School of the University of Western Australia, Crawley, Western Australia, Australia
| | - Andrea Bille
- Department of Thoracic Surgery, Guy's Hospital, London, United Kingdom
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Ontario, Canada
| | - Hedy L Kindler
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - David Rice
- Department of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harvey I Pass
- Department of Cardiothoracic Surgery, New York University (NYU) Langone Medical Center, New York, New York
| |
Collapse
|
4
|
Magouliotis DE, Zotos PA, Rad AA, Koukousaki D, Vasilaki V, Portesi I, Spiliopoulos K, Athanasiou T. Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy/decortication (P/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR). Updates Surg 2022. [PMID: 36057027 DOI: 10.1007/s13304-022-01369-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/20/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D). METHODS Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1980 to February 2022. The 30-days and 90-day mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival, the macroscopic complete resection (MCR) rate, and the complications were calculated according to both a fixed and a random effect model. The Q and I2 statistic were used to test for heterogeneity among the studies. Sensitivity analysis was performed including only studies that incorporated the MCR concept. RESULTS Eighteen studies were included, incorporating a total of 4,852 patients treated with EPP and P/D. The 30-day mortality was significantly higher in the EPP group (OR: 2.79 [95% CI 1.30, 6.01]; p = 0.009). The median overall survival was higher in the P/D group (WMD:-4.55 [-6.05, -3.04]; p < 0.001). No differences were found regarding the 90-day mortality, MCR rate, and the 1-, 2-,3-, 5-year survival between the EPP and P/D groups. These findings were validated by the sensitivity analysis. The incidence of atrial fibrillation, hemorrhage, pulmonary embolism, air leak, and reoperation was significantly increased in the EPP group (p < 0.05). CONCLUSIONS The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach should be preferred when technically feasible. However, the procedure of choice should be decided based on the goal of MCR in the safest approach for the patient.
Collapse
|
5
|
Greb D, Hebeisen M, Matter A, Opitz I, Lauk O. Prospective validation and extension of the Multimodality Prognostic Score for the treatment allocation of pleural mesothelioma patients. Eur J Cardiothorac Surg 2022; 62:6546747. [PMID: 35274127 PMCID: PMC9334788 DOI: 10.1093/ejcts/ezac085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Daria Greb
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Monika Hebeisen
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Alessandra Matter
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olivia Lauk
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
6
|
Sonobe M, Kou Y, Yamazaki N, Sakaguchi Y, Tanaka H. Staged removal of artificial patches for thoracic empyema after extrapleural pneumonectomy for diffuse malignant pleural mesothelioma. Gen Thorac Cardiovasc Surg 2021. [PMID: 34676483 DOI: 10.1007/s11748-021-01723-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
A 69-year-old man with occupational exposure to asbestos was referred to our hospital with right diffuse malignant pleural mesothelioma. He underwent extrapleural pneumonectomy with reconstruction of the pericardium and diaphragm using elongated polytetrafluoroethylene patches, followed by postoperative chemotherapy and chest wall irradiation. One year later, he was hospitalized because of a right empyema caused by Escherichia coli infection. As chest drainage and systemic antibiotics did not eliminate the abscess around the artificial patches, a Clagett window was created. To avoid mediastinal and liver overshift into the right thoracic cavity, we only performed partial resection of the diaphragm patch and incision of the artificial pericardium. After 19 days of irrigation and dressing change, the artificial patches were completely removed. Two months later, the patient provided a culture-negative sample and had an improved nutritional status; we therefore performed closure of the Clagett window with thoracoplasty. He did not experience recurrence of empyema.
Collapse
|
7
|
Nakamura A, Hashimoto M, Matsumoto S, Kondo N, Kijima T, Hasegawa S. Outcomes of Conversion to Extrapleural Pneumonectomy From Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Semin Thorac Cardiovasc Surg 2021; 33:873-881. [PMID: 33609685 DOI: 10.1053/j.semtcvs.2021.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
In recent years, there has been a shift from extrapleural pneumonectomy (EPP) toward pleurectomy/decortication (P/D) as the preferred surgical technique. However, we occasionally encounter difficult cases wherein visceral pleurectomy requires conversion to EPP from P/D. We sought to clarify the preoperative risk factors and clinical outcomes associated with conversion to EPP. We compared and analyzed conversion to EPP and P/D between September 2012 and December 2019. Conversion to EPP was decided in case of diffuse tumor invasion to the pulmonary parenchyma or due to failure of decortication. Univariable regression analysis was performed to determine the association of preoperative variables with conversion to EPP. Survival was analyzed by the Kaplan-Meier method and log-rank test. Of the 181 patients who underwent intended P/D, 145 (80.1%) patients underwent P/D and 18 (9.9%) patients underwent conversion to EPP. The sum of 3-level pleural thickness (P < 0.001), maximum of 3-level pleural thickness (P = 0.006), and clinical T stage (P < 0.001) demonstrated association with conversion to EPP. Overall survival and progression-free survival were significantly worse in the conversion to EPP group (median overall survival, 29.2 months vs 57.0 months [P = 0.008]; median progression-free survival, 15.3 months vs 23.2 months [P = 0.005]. Our data show that approximately 1 of every 10 patients with P/D intention converted to EPP. Preoperative pleural thickness and clinical T stage may be risk factors associated with conversion to EPP. The survival rate of conversion to EPP was worse than that of P/D.
Collapse
Affiliation(s)
- Akifumi Nakamura
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan.
| | - Masaki Hashimoto
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Seiji Matsumoto
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Nobuyuki Kondo
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Kijima
- Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Seiki Hasegawa
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| |
Collapse
|
8
|
Abstract
While without treatment, malignant pleural mesothelioma (MPM) confers poor survival, cancer-directed surgery as part of multimodality treatment is associated with a 15% 5-year survival. Extrapleural pneumonectomy (EPP) and radical or extended pleurectomy/decortication (P/D) are the 2 types of resection performed in this context. Preoperative staging is critical to patient selection for surgery; P/D is recommended over EPP in most cases. Adjuvant therapy with intraoperative platforms, traditional chemotherapy, hemithoracic radiotherapy resection, and new immunotherapy agents are instrumental in achieving durable long-term results. We outline the latest understanding of disease staging and describe the current state of literature and practice.
Collapse
Affiliation(s)
- Andrea S Wolf
- Department of Thoracic Surgery, The Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1023, New York, NY 10029, USA.
| | - Raja M Flores
- Department of Thoracic Surgery, The Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1023, New York, NY 10029, USA
| |
Collapse
|
9
|
Kondo N, Hashimoto M, Takuwa T, Matsumoto S, Okumura Y, Hasegawa S. Treatment of bronchial fistula after extraplural pneumonectomy using flexible bronchoscopy with the administration of OK432, fibroblast growth factor basic and fibrin glue sealant. Gen Thorac Cardiovasc Surg 2020; 68:1562-1564. [PMID: 32279197 DOI: 10.1007/s11748-020-01349-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
Treatment options for bronchial fistula (BF) after pneumonectomy are often limited and carry significant morbidity and mortality. The patient underwent right extrapleural pneumonectomy for malignant pleural mesothelioma had BF without macroscopic fistula found by bronchography. We treated this minor BF using bronchoscopy with the administration of OK-432, fibroblast growth factor basic, and fibrin glue sealant. Two weeks after this treatment, we confirmed the improvement of the fistula by bronchography. Bronchoscopic therapy for BF was useful for a small, early fistula without infection.
Collapse
Affiliation(s)
- Nobuyuki Kondo
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Masaki Hashimoto
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Teruhisa Takuwa
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Seiji Matsumoto
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshitomo Okumura
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.,Department of Thoracic Surgery, Itami Municipal Hospital, Hyogo, Japan
| | - Seiki Hasegawa
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| |
Collapse
|
10
|
Verma V, Wegner RE, Stahl JM, Barsky AR, Raghavan D, Busquets TE, Hoppe BS, Grover S, Friedberg JS, Simone CB. Impact of Detecting Occult Pathologic Nodal Disease During Resection for Malignant Pleural Mesothelioma. Clin Lung Cancer 2020; 21:e274-e285. [PMID: 32057688 DOI: 10.1016/j.cllc.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/21/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lymph node (LN) involvement is a poor prognostic factor for malignant pleural mesothelioma (MPM). However, to our knowledge, postresection outcomes of node-negative (cN0/pN0), occult pathologic nodal disease (cN0/pN+), and clinical node-positive disease (cN+) have not been compared to date. PATIENTS AND METHODS The National Cancer Data Base was queried for newly diagnosed, resected MPM with known clinical/pathologic LN information. Three cohorts were compared: cN0/pN0, cN+, and cN0/pN+. Multivariable logistic regression examined predictors of pathologic nodal upstaging. Kaplan-Meier analysis with propensity matching assessed overall survival (OS); multivariate Cox proportional hazards modeling examined predictors thereof. RESULTS Of 1369 patients, 687 (50%) had cN0/pN0, 457 (33%) cN+, and 225 (16%) cN0/pN+ disease. Median follow-up was 29 months. In patients with cN0 disease, factors associated with pathologic nodal upstaging were younger age, greater number of examined LNs, and nonsarcomatoid histology (P < .05 for all). Relative to pN0 cases, occult LN involvement (65% being pN2) was associated with 51% higher hazard of mortality on multivariate analysis (P = .005). Following propensity matching, the OS of cN0/pN+ was similar to cN+ cases (P = .281). On multivariate analysis, the number of involved LNs (continuous variable, P = .013), but not nodal tumor, node, metastasis (TNM) classification or LN ratio (P > .05 for both), was associated with OS. CONCLUSION Detecting occult nodal disease during resection for cN0 MPM is associated with poorer prognosis, with similar survival as cN+ cases, underscoring the importance of routine preoperative pathologic nodal assessment for potentially resectable MPM. The number of involved LNs (rather than current location-based classification) may provide more robust prognostic stratification for future TNM staging.
Collapse
Affiliation(s)
- Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew R Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Deepta Raghavan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Talia E Busquets
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, FL
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Joseph S Friedberg
- Department of Surgery, Division of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY.
| |
Collapse
|
11
|
Itano H, Takeda T, Yamada T, Koide M, Kobayashi T. Heterologous sarcomatoid pleural mesothelioma with osteosarcomatous differentiation: a report of autopsy case that accomplished trimodality therapy and review of the literature. Gen Thorac Cardiovasc Surg 2020; 68:871-9. [PMID: 31372931 DOI: 10.1007/s11748-019-01182-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
Heterologous mesothelioma is a very rare subtype of sarcomatoid mesothelioma characterized by the presence of malignant heterologous elements. A 69-year-old man with a strong history of asbestos exposure presented with a 5-cm mass in his chest wall, destroying the right 5th rib and spreading along the parietal pleura, on a CT. Biopsy revealed heterologous mesothelioma with osteosarcomatous elements, following which left extrapleural pneumonectomy was performed with combined resection of pericardium, hemidiaphragm, and 4th, 5th, and 6th costal segments. A small cytokeratin-positive epithelioid component in the resected tumor definitively confirmed the diagnosis. Post-operative chemotherapy and intensity-modulated radiotherapy were undertaken. After 12-month disease-free period post treatment, rapid intraperitoneal recurrence resulted in death. Autopsy revealed no tumors in the left thorax. We present here a case of heterologous osteosarcomatous pleural mesothelioma that followed a unique clinical course after trimodality therapy. In addition, literature of 54 cases of the similar heterologous mesothelioma was reviewed.
Collapse
|
12
|
Riesterer O, Ciernik IF, Stahel RA, Xyrafas A, Aebersold DM, Plasswilm L, Mahmut Ozsahin E, Zwahlen DR, Nackaerts K, Zimmermann F, Sabrina Stark L, Weder W, Krayenbuehl J. Pattern of failure after adjuvant radiotherapy following extrapleural pneumonectomy of pleural mesothelioma in the SAKK 17/04 trial. Radiother Oncol 2019; 138:121-125. [PMID: 31252293 DOI: 10.1016/j.radonc.2019.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/21/2022]
Abstract
Postoperative radiotherapy after extrapleural pneumonectomy of malignant pleural mesothelioma was investigated in the randomized phase II trial SAKK17/04. The relapse rate within the high and/or low-dose PTV without previous distant failure was 24%, the isolated in-field-relapse rate within the PTVs was 5% and the distant relapse rate outside of the PTVs was 81%. Clinical outcome was mainly determined by distant disease progression outside of the radiation field.
Collapse
Affiliation(s)
- Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland; Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Switzerland.
| | - I Frank Ciernik
- Department of Radiotherapy and Radiation Oncology, Dessau, Germany
| | - Rolf A Stahel
- Cancer Center Zurich, University Hospital Zurich, University of Zurich, Switzerland
| | - Alexandros Xyrafas
- Swiss Group for Clinical Cancer Research (SAKK) Coordinating Center, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, University Hospital Bern, University of Bern, Switzerland
| | - Ludwig Plasswilm
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, University of Bern, Switzerland
| | - E Mahmut Ozsahin
- Department of Radiation Oncology, University Hospital Lausanne - CHUV, Lausanne, Switzerland
| | - Daniel R Zwahlen
- Department of Radiation Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Kristiaan Nackaerts
- Department of Pneumology, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Frank Zimmermann
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - L Sabrina Stark
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Walter Weder
- Thoracic Surgery Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Jérôme Krayenbuehl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| |
Collapse
|
13
|
Nishikawa S, Tamari S, Okita K, Chihara K. Successful treatment of late onset empyema after extrapleural pneumonectomy: A case report. Respir Med Case Rep 2019; 26:174-175. [PMID: 30671340 PMCID: PMC6327906 DOI: 10.1016/j.rmcr.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/03/2019] [Accepted: 01/03/2019] [Indexed: 11/30/2022] Open
Abstract
Treatment of post-extrapleural pneumonectomy empyema (PEPPE) is more difficult than that for post-pneumonectomy empyema for two reasons: first, a large infectious dead space remains after extrapleural pneumonectomy (EPP); and second, defects of the pericardium and diaphragm are reconstructed with artificial materials, which ideally should be removed for treatment of infection. Here, we report the case of a 56-year-old male with PEPPE that occurred long after EPP for mesothelioma. The patient was treated successfully by minimally invasive procedures of irrigation, instillation of urokinase and antibiotics, and surgical debridement without peeling off artificial materials.
Collapse
Affiliation(s)
- Shigeto Nishikawa
- Division of Thoracic Surgery, Shizuoka City Shizuoka Hospital, Ohtemachi, 10-93, Aoi-ku, 420-8630, Shizuoka, Japan
| | - Shigeyuki Tamari
- Division of Thoracic Surgery, Shizuoka City Shizuoka Hospital, Ohtemachi, 10-93, Aoi-ku, 420-8630, Shizuoka, Japan
| | - Kenji Okita
- Division of Thoracic Surgery, Shizuoka City Shizuoka Hospital, Ohtemachi, 10-93, Aoi-ku, 420-8630, Shizuoka, Japan
| | - Koji Chihara
- Division of Thoracic Surgery, Shizuoka City Shizuoka Hospital, Ohtemachi, 10-93, Aoi-ku, 420-8630, Shizuoka, Japan
| |
Collapse
|
14
|
Soldera SV, Kavanagh J, Pintilie M, Leighl NB, de Perrot M, Cho J, Hope A, Feld R, Bradbury PA. Systemic Therapy Use and Outcomes After Relapse from Preoperative Radiation and Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma. Oncologist 2018; 24:e510-e517. [PMID: 30478189 DOI: 10.1634/theoncologist.2018-0501] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/16/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Multimodality therapy with preoperative radiation (RT) followed by extrapleural pneumonectomy (EP) for patients with operable malignant pleural mesothelioma (MPM) has demonstrated encouraging results. At relapse, there are few data on the tolerance and efficacy of systemic therapies after prior multimodality therapy. MATERIALS AND METHODS We conducted a retrospective analysis of patients with relapsed MPM after RT and EPP ± adjuvant chemotherapy to determine overall survival (OS; date of relapse to death) and the proportion of patients that received systemic therapy and associated response rate (RR). OS was estimated using Kaplan-Meier method and potential prognostic variables were examined. RESULTS Fifty-three patients were included (2008-2016). Median OS was 4.8 months (median follow-up 4.4 months, range 0.03-34.8). Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2, disease-free interval (DFI) <1 year, and hemoglobin ≤110 g/L at recurrence were associated with worse prognosis. Thirty-six percent of patients received any systemic therapy, whereas it was omitted in 62% because of poor PS. RR was 15% (0 complete responses, 15% partial responses) in 13 individuals with response-evaluable disease. Therapy was discontinued because of toxicity (6/15) or disease progression (5/15), and median number of cycles was four. CONCLUSION Patients with relapsed MPM following RT and EPP, especially those with ECOG PS ≥2, DFI <1 year, and hemoglobin ≤110 g/L at recurrence, have poor prognosis and low RR to first-line systemic therapy. Earlier detection and novel diagnostic markers of relapse as well as potential neoadjuvant or adjuvant systemic therapy should be investigated in future studies. IMPLICATIONS FOR PRACTICE The results of this study have reinforced the importance of careful selection of appropriate candidates for this combined-modality approach and favor prompt detection of recurrence with early and regular postoperative imaging and biopsy of suspected relapsed disease along with rapid initiation of systemic therapy even in patients with very low burden of disease. Furthermore, with the emergence of new systemic agents targeting different histological subtypes of malignant pleural mesothelioma, histological sampling of recurrence could inform therapeutic decisions in the future.
Collapse
Affiliation(s)
- Sara V Soldera
- Department of Hematology and Oncology, CISSS Montérégie Centre/Hôpital Charles-Lemoyne, Université Sherbrooke, Quebec, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - John Kavanagh
- Department of Radiology, University Health Network, University of Toronto, Toronto, Canada
| | - Melania Pintilie
- Biostatistics Division, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Natasha B Leighl
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Marc de Perrot
- Department of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Ronald Feld
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Penelope A Bradbury
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| |
Collapse
|
15
|
Magouliotis DE, Tasiopoulou VS, Athanassiadi K. Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma. Gen Thorac Cardiovasc Surg 2019; 67:312-20. [PMID: 30374811 DOI: 10.1007/s11748-018-1027-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/24/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D). METHODS Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1990 to July 2018. The 30 and 90 days mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival and the complications were calculated according to both a fixed and a random effect model. The Q statistics and I2 statistic were used to test for heterogeneity among the studies. RESULTS Fifteen studies were included, incorporating a total of 1672 patients treated with EPP and 2236 treated with P/D. The 30-day mortality was significantly higher in the EPP group [OR 3.24 (95% CI 1.70, 6.20); p < 0.001]. The median overall survival was significantly increased in the P/D group [WMD - 4.20 (- 5.66, - 2.74); p < 0.001]. No significant differences were found regarding the 90-day mortality and the 1-, 2-, 3-, 5-year survival between the EPP and P/D groups. The incidence of postoperative atrial fibrillation, hemorrhage, empyema, bronchopleural fistula and air leak was significantly increased in the EPP group (p < 0.05). CONCLUSIONS The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach, should, therefore be preferred when technically feasible. However, the decision regarding the procedure of choice should be made on the basis of the disease status and the surgeon's experience. Well-designed, randomized studies, comparing EPP to P/D, are necessary to further assess their clinical outcomes.
Collapse
|
16
|
Casiraghi M, Maisonneuve P, Brambilla D, Solli P, Galetta D, Petrella F, Piperno G, De Marinis F, Spaggiari L. Induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2018; 52:975-981. [PMID: 28482086 DOI: 10.1093/ejcts/ezx122] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/23/2017] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES While the best approach to malignant pleural mesothelioma has yet to be demonstrated, surgery remains the mainstay of treatment. We analysed a group of candidates for trimodality treatment, aiming to identify prognostic factors guiding patient selection. METHODS Between 2003 and 2015, 83 (31.6%) of the 283 patients with malignant pleural mesothelioma were considered for trimodality treatment to perform induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy. All patients underwent cisplatin-based chemotherapy. Radiotherapy was administered at a mean dose of 50.4 Gy. RESULTS Thirty-six patients (43.4%) had 3 cycles of chemotherapy, whereas 21 (25.3%) had more than 3. Progression to chemotherapy was observed in 10.9% (9 of 83) of patients, partial response in 30.1% (25 of 83) and stable disease in 59% (49 of 83). Sixty-three patients underwent extrapleural pneumonectomy. Fifty-five patients (87.3%) had epithelial tumour. Forty-two patients (66.7%) were in pathological Stage 3. Major complications after extrapleural pneumonectomy were observed in 28 patients (44.4%), whereas 30-day postoperative mortality was 11.1% (7/63). Radiotherapy was not administered in 24 patients (38.1%) due to major complications after surgery or patient intolerance. Two patients (3.2%) died within 90 days after the end of radiotherapy. The trimodality treatment was completed in 37 (44.6%) patients. Median overall survival was 35.6 months, with 1- and 3-year overall survival of 82% and 48% for patients who completed the trimodality treatment compared with 32% and 14% for patients who did not undergo radiotherapy. CONCLUSIONS Only 45% of patients completed the planned trimodality treatment, and morbidity/mortality remained high. Nonetheless, the patients who completed treatment showed good loco-regional disease control and better overall survival.
Collapse
Affiliation(s)
- Monica Casiraghi
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - Daniela Brambilla
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
| | - Piergiorgio Solli
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
| | - Domenico Galetta
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
| | - Francesco Petrella
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy
| | - Gaia Piperno
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Filippo De Marinis
- Division of Clinical Oncology, European Institute of Oncology, Milan, Italy
| | - Lorenzo Spaggiari
- Division of Thoracic Surgery, European Institute of Oncology, University of Milan, Milan, Italy.,Department of Oncology and Hematology (DIPO), School of Medicine, University of Milan, Milan, Italy
| |
Collapse
|
17
|
Moser B, Fadel E, Fabre D, Keshavjee S, de Perrot M, Thomas P, Brioude G, Van Raemdonck D, Viskens S, Lang-Lazdunski L, Bille A, Weder W, Jungraithmayr W, Ruffini E, Guerrera F, Gómez de Antonio D, Liberman M, Novoa N, Scarci M, Janik S, Klepetko W. Surgical therapy of thymic tumours with pleural involvement: an ESTS Thymic Working Group Project. Eur J Cardiothorac Surg 2018; 52:346-355. [PMID: 28449028 PMCID: PMC5848821 DOI: 10.1093/ejcts/ezx090] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/26/2017] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES: Surgery for thymic epithelial tumours (TETs) with pleural involvement is infrequently performed. Thus, the value of surgical therapy for primary or recurrent TETs with pleural involvement is not sufficiently defined yet. METHODS: Twelve institutions contributed retrospective data on 152 patients undergoing surgery (1977–2014) on behalf of the ESTS Thymic Working group. Outcome measures included overall (OS), cause-specific (CSS) and disease-free (DFS) survival as well as freedom from recurrence (FFR). RESULTS: In 70.4% of cases, pleural involvement was present at the time of primary intervention, whereas 29.6% had surgery for recurrent disease involving the pleura. Pleural involvement resulted from thymomas (88.8%) and thymic carcinomas (11.2%). Forty extrapleural pneumonectomies (EPPs), 23 total pleurectomies (TPs), and 88 local pleurectomies (LPs) were performed (completeness of resection in 76.8%). OS for the entire patient population at 1, 3, 5 and 10 years was 96.4%, 91.0%, 87.2% and 62.7%, respectively. There was no statistically significant difference regarding FFR and OS for patients with local or advanced disease undergoing EPP, TP or LP. Thymic carcinomas in comparison with thymomas had a negative impact on OS [hazard ratio 6.506, P = 0.002], CSS and FFR. Incomplete resections predicted worse OS [hazard ratio 6.696, P = 0.003]. CONCLUSIONS: Complete resection remains the mainstay of treatment for TETs with pleural involvement. Study populations treated with EPP, TP and LP had similar survival that may be factual as observed, but in the presence of selection bias, we can further conclude from the results that EPP, TP and LP are equally effective procedures. Procedural choice depends upon the extent of tumour distribution. EPPs, TPs and LPs performed within a multimodality setting seem to be efficient procedures for local control of disease, as they yield excellent results regarding OS, DFS, CSS and FFR.
Collapse
Affiliation(s)
- Bernhard Moser
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Paris Sud University, Paris, France
| | - Dominique Fabre
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Paris Sud University, Paris, France
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Pascal Thomas
- Department of Thoracic Surgery, Aix-Marseille University, Marseille, France
| | - Geoffrey Brioude
- Department of Thoracic Surgery, Aix-Marseille University, Marseille, France
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sophie Viskens
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Loic Lang-Lazdunski
- Department of Thoracic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrea Bille
- Department of Thoracic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Walter Weder
- Division of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | | | - Enrico Ruffini
- Department of Surgery, Section of Thoracic Surgery, University of Torino, Torino, Italy
| | - Francesco Guerrera
- Department of Surgery, Section of Thoracic Surgery, University of Torino, Torino, Italy
| | - David Gómez de Antonio
- Department of Thoracic Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, University of Montréal, Montreal, QC, Canada
| | - Nuria Novoa
- Service of Thoracic Surgery, University Hospital, Salamanca, Spain
| | - Marco Scarci
- Department of Thoracic Surgery, University College London Hospital, London, UK
| | - Stefan Janik
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| |
Collapse
|
18
|
Lau B, Kumar S, Yan T, Burn J, Kennedy C, McLean J, Boyer M, McCaughan B, Kao S. Pathological complete response in malignant pleural mesothelioma patients following induction chemotherapy: Predictive factors and outcomes. Lung Cancer 2017; 111:75-78. [PMID: 28838403 DOI: 10.1016/j.lungcan.2017.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 03/30/2017] [Accepted: 07/09/2017] [Indexed: 11/26/2022]
Abstract
A small proportion of patients with malignant pleural mesothelioma (MPM) achieve pathological complete response (CR) following treatment with current practice induction chemotherapy. Our analysis of 58 patients with MPM treated with platinum-based chemotherapy showed 4 patients (7%) attained pathological CR at subsequent extrapleural pneumonectomy (EPP). Patient and tumour factors such as age, gender, smoking habit, histological subtype, and clinical stage were not found to be associated with pathological CR. Patients with pathological CR had longer disease-free survival (29.2 vs. 13.8 months; p=0.08) and overall survival (76.4 vs. 23.4 months; p=0.06) but this did not reach statistical significance. Our study suggests that patients who achieve pathological CR after chemotherapy may have improved survival in MPM.
Collapse
Affiliation(s)
- Brandon Lau
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Sanjeev Kumar
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia; Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Tristan Yan
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Juliet Burn
- Douglas Hanly Moir Pathology, Sydney, Australia
| | - Catherine Kennedy
- Sydney Medical School, The University of Sydney, Sydney, Australia; Strathfield Private Hospital, Sydney, Australia
| | | | - Michael Boyer
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Brian McCaughan
- Sydney Medical School, The University of Sydney, Sydney, Australia; Sydney Cardiothoracic Surgeons, Sydney, Australia
| | - Steven Kao
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia; Asbestos Diseases Research Institute, Sydney, Australia.
| |
Collapse
|
19
|
Infante M, Morenghi E, Bottoni E, Zucali P, Rahal D, Morlacchi A, Ascolese AM, De Rose F, Navarria P, Crepaldi A, Testori A, Voulaz E, Errico V, Perrino M, Scorsetti M, Chiti A, Santoro A, Alloisio M. Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2016; 50:1077-1082. [PMID: 27330149 DOI: 10.1093/ejcts/ezw215] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES We examined a series of malignant pleural mesothelioma (MPM) patients who underwent radical surgery to explore relationships among comorbidity, postoperative morbidity and survival. METHODS A retrospective analysis was carried out of all MPM patients operated on in a single centre from 2000 to 2015. The Charlson Comorbidity Index (CCI) was used to classify patients according to their underlying condition. Postoperative complications were scored according to WHO-derived criteria. Survival comparisons were performed by Cox analysis. RESULTS Ninety-one patients underwent extrapleural pneumonectomy (EPP), 47 underwent pleurectomy decortication (PD) and 25 underwent palliative pleurectomy. The mean CCI of PD patients was significantly higher compared with that of EPP patients (P= 0.044). The frequency of grade 3+ complications was similar between EPP and PD (27 vs 26%). However, EPP patients had a 6-fold higher frequency of pleural sepsis (24 vs 4%, P= 0.002) occurring up to 695 days postoperatively. Median overall survival was 19 months (95% CI 13-25) after EPP, 30 months (95% CI 20-35) after PD and 13 months (95% CI 5-32) after palliative pleurectomy. At multivariate analysis, CCI (P< 0.001), histology (P= 0.014) and pleural sepsis (P= 0.001), but not complete resection, were significantly associated with survival. There was a trend in favour of PD over palliative resection after adjusting for histology and CCI. CONCLUSIONS The CCI is an independent predictor of survival in MPM patients undergoing radical surgery. Owing to its significant frequency and adverse impact, pleural sepsis may contribute to a reduced life expectancy after EPP. Surgical treatment of MPM remains debatable.
Collapse
Affiliation(s)
- Maurizio Infante
- Department of Thoracic Surgery, University Hospital Borgo Trento, Verona, Italy
| | - Emanuela Morenghi
- Clinical Research Unit, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Edoardo Bottoni
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Paolo Zucali
- Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy
| | - Daoud Rahal
- Department of Pathology, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Andrea Morlacchi
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Anna Maria Ascolese
- Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Fiorenza De Rose
- Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Alessandro Crepaldi
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Alberto Testori
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Emanuele Voulaz
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Valentina Errico
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Matteo Perrino
- Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Arturo Chiti
- Nuclear Medicine, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy
| | - Armando Santoro
- Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy
| | - Marco Alloisio
- Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
| |
Collapse
|
20
|
Sharkey AJ, Bilancia R, Tenconi S, Nakas A, Waller DA. The management of the diaphragm during radical surgery for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2016; 50:311-6. [PMID: 27005974 DOI: 10.1093/ejcts/ezw045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/26/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Macroscopic complete resection with lung preservation is the objective of radical management of pleural mesothelioma (MPM). Total removal of visceral and parietal pleura (pleurectomy/decortication) almost invariably proceeds to an extended pleurectomy/decortication (EPD) to ensure macroscopic complete resection. We suspected this may not always be necessary. METHODS We reviewed 314 patients, 86.0% male, median age 62 years (range 14-81 years) undergoing radical surgery for MPM from 1999 to 2014, by either EPD or extrapleural pneumonectomy. The extent of diaphragmatic muscle involvement was recorded from postoperative pathology. Patients were divided into three groups: no involvement, non-transmural, transmural diaphragmatic invasion. RESULTS A total of 213 (68%) patients underwent EPD, 237 (75.5%) had epithelioid disease and 57.6% were node positive. There was no difference between the three groups in terms of age, cell type, laterality, neoadjuvant chemotherapy and operation. There was a higher degree of diaphragm involvement in females (P = 0.01) and in patients with positive lymph nodes (P = 0.01). No evidence of diaphragmatic involvement was found following pathological assessment of the resection specimen in 119 patients (37.9%). The incidence of abdominal disease progression was 23.9%. There was no correlation with degree of diaphragmatic invasion (ρ = 0.01 P = 0.88). Overall survival of those with abdominal progression was similar to those with progression elsewhere: 14.5 vs 13.0 months (P = 0.79), and with those with no progression (16.7 months, P = 0.189). There was no difference in survival when stratified by diaphragmatic involvement (P = 0.44). CONCLUSIONS In our cohort, there was no evidence of diaphragmatic invasion in over 30% of patients, and we have also failed to find evidence that peritoneal disease progression affects overall survival following radical management. It may therefore theoretically be unnecessary to resect the diaphragm in all cases, and a pleurectomy-decortication could suffice. However, there is an unknown risk of R2 resection which would prejudice survival, and as such we would advocate resecting the diaphragm in all cases to avoid an R2 resection.
Collapse
|
21
|
Sharkey AJ, Tenconi S, Nakas A, Waller DA. The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy/decortication. Eur J Cardiothorac Surg 2015; 49:1632-41. [PMID: 26637211 DOI: 10.1093/ejcts/ezv403] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES For many years, extrapleural pneumonectomy (EPP) was the operation of choice for the radical management of pleural mesothelioma in the UK. However, doubts surrounding the efficacy of EPP, and the change in demographics of the affected population, have prompted a transition in our practice towards extended pleurectomy/decortication (EPD). The aim of this study was to determine the effects an intentional transition from EPP to EPD has had on patient outcome. METHODS Data from 362 patients undergoing radical surgery (229 EPD, 133 EPP) during 1999-2014 were included. Demographics and outcome were compared between the two groups; EPP versus EPD. RESULTS The median age of patients undergoing EPD was significantly higher than those undergoing EPP [57 years (range 14-70 years) vs 65 years (range 42-81 years), P < 0.001]. There was a significantly higher proportion of patients with performance status ≥1 in the EPD group (46.3 vs 35.4%, P = 0.047). There was no difference in the median length of hospital stay between the two groups [14 days (range 1-133 days) vs 13 days (range 0-93 days), P = 0.409]. There was also no difference between the groups in terms of in-hospital mortality (EPP 5.3% and EPD 6.6%, P = 0.389), 30-day mortality [EPP 8 (6.0%) and EPD 8 (3.5%), P = 0.294] or 90-day mortality [EPP 18 (13.5%) and EPD 21 (9.2%), P = 0.220]. There was a significantly higher early reoperation rate in the EPP group (15.0 vs 6.2%, P = 0.008) but a significantly higher late reoperation rate in the EPD group (0.8 vs 5.3%, P = 0.037). There was no significant difference in overall survival or disease-free interval between the two groups (P = 0.899 and P = 0.399, respectively). However, overall survival was significantly greater in patients over the age of 65 undergoing EPD (12.5 vs 4.7 months, P = 0.001). CONCLUSION The transition from EPP to EPD in our standard practice has enabled us to operate on more elderly, frail patients with no significant increase in use of hospital resources, and without detriment to overall survival.
Collapse
|
22
|
Abstract
Malignant pleural mesothelioma (MPM) is associated with a poor prognosis. The main components of multimodality treatment include surgery, chemotherapy, and radiation therapy. Surgery remains controversial. Two procedures are currently offered: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). The recent scientific literature suggests that P/D is a well-tolerated procedure, with the potential of becoming a default procedure in multimodality regimens. However, the precise treatment schemes and surgical procedures are yet to be established. In our study, we review the advantages and disadvantages of EPP and P/D, summarize the post-EPP and post-P/D observations (including mortality, morbidity, and median survival time), and discuss the choice of surgical technique (EPP vs. P/D). Moreover, we highlight the aspects of the multimodality treatments that are offered to MPM patients, including chemotherapy, radiotherapy, intensity-modulated radiation therapy, and other types of therapy.
Collapse
|
23
|
Yamaguchi M, Ichinose Y, Shimamatsu S, Yoshida T, Toyokawa G, Nosaki K, Hirai F, Seto T, Takenoyama M. Preoperative concurrent chemoradiotherapy followed by extrapleural pneumonectomy for patients with non-small cell lung cancer with malignant pleural effusion and/or pleural nodules: Ten-year results of a prematurely terminated single institute phase II trial. Surg Oncol 2015; 24:78-83. [PMID: 25818753 DOI: 10.1016/j.suronc.2015.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/21/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Malignant pleural effusion and/or pleural nodules are a final stage of disease extension of non-small cell lung cancer (NSCLC), which is currently classified as M1a-Stage IV disease. The role of surgery, especially extrapleural pneumonectomy (EPP) for local disease control and its impact on the survival of patients remains uncertain. PATIENTS AND METHODS This single institute phase II trial was performed from March 1997 to March July 2004 to assess the effects of induction concurrent chemoradiotherapy (CRT) using a pro-drug of 5-FU, uracil-tegafur (UFT(®), Taiho Pharmaceutical Co., Ltd, Tokyo, Japan), plus cisplatin concurrently with 40 Gy hemithorax radiation followed by EPP. Intraoperative hypotonic cisplatin treatment in the pleural cavity before resection of the pericardium and diaphragm was performed. The primary endpoint of this study was the overall survival (OS), and the secondary endpoint was the disease-free survival (DFS), safety, response to the induction CRT, local disease control period in the affected thorax and the type of disease recurrence. RESULTS This trial was prematurely terminated because of the slow registration pace. During the study period, 11 patients were enrolled. There were five males and six females, with a median age of 55 (36-64) years. All patients had adenocarcinoma. All patients received the planned induction CRT. Five patients achieved a partial response and five achieved stable disease, and one patient could not be evaluated. One patient underwent exploratory thoracotomy due to unresectable chest wall invasion, and nine patients (81.8%) underwent EPP. No perioperative deaths were encountered. The median follow-up time was matured at 32.1 (range 15.0-100) months. The one-, three- and five-year DFS rates were 77.8% (95%CI: 50.6-100%), 11.1% and 11.1% (95%CI: 95%CI: 0-31.7%), respectively. The one-, three- and five-year OS rates were 100.0%, 33.3% (95%CI: 2.5-64.1%) and 22.2% (95%CI: 0.0-49.4%), respectively. Recurrence developed in eight of nine patients who underwent EPP (88.9%). All first recurrent sites were distant regions, and no ipsilateral local recurrence was identified. CONCLUSION The trimodality treatment used in this trial appears to be a choice of treatment for highly selected patients. However, the impact on the survival of NSCLC patients with malignant pleural effusion and/or pleural nodules still remains uncertain given the small number of patients enrolled in the study.
Collapse
Affiliation(s)
- Masafumi Yamaguchi
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan.
| | - Yukito Ichinose
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Shinichiro Shimamatsu
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Tsukihisa Yoshida
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Gouji Toyokawa
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Kaname Nosaki
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Fumihiko Hirai
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Takashi Seto
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| | - Mitsuhiro Takenoyama
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka City 811-1395, Japan
| |
Collapse
|
24
|
Abstract
OBJECTIVES The aim of radical surgery for malignant pleural mesothelioma (MPM) is to achieve greater survival than from chemotherapy alone. Although adverse overall prognostic factors have already been determined, our aim was to identify the most important factors affecting long-term survival arbitrarily defined as >24 months. METHODS We retrospectively reviewed the records of 252 patients (35 females; 193 epithelioid and 59 biphasic; 112 extrapleural pneumonectomy (EPP); 140 extended pleurectomy decortication (EPD)) who survived for at least 90 postoperative days. We tested for factors affecting overall cancer-related mortality and specific clinical factors predicting the 24-month survival. RESULTS The overall median survival was 18.2 (SE 1.3, 95% CI 15.8-20.7 months). There was no difference in survival between EPP and EPD (P = 0.92). One hundred and twenty-eight patients received induction, adjuvant or palliative chemotherapy. Seventy-seven (30.6%) patients survived for >24 months. On univariate analysis, age at operation over 60 years (P = 0.044), pT4 stage (P = 0.041), any lymph node metastases (P = 0.002), biphasic cell type (P = 0.00) and no administration of chemotherapy (P = 0.00) were associated with decreased survival. On multivariate analysis, age <60 (P = 0.018, OR = 0.7), epithelioid disease (P = 0.001, OR = 0.56) and negative nodes (P = 0.009, OR = 0.67) were associated with increased survival and no administration of chemotherapy (P = 0.00, OR = 1.9) with decreased survival. Factors predicting survival over 24 months included: age at operation under 60 (P = 0.014), epithelioid histology (P ≤ 0.00), negative nodes (P = 0.002) and chemotherapy (P = 0.022). CONCLUSIONS These results support a policy of accurate preoperative tissue diagnosis, nodal staging and induction chemotherapy prior to radical surgery for MPM, which can result in long-term survival. Trials investigating the role of surgery should be focused on confirming and refining these selection criteria.
Collapse
Affiliation(s)
- Apostolos Nakas
- Department of Thoracic Surgery Glenfield Hospital, Leicester, UK
| | - David Waller
- Department of Thoracic Surgery Glenfield Hospital, Leicester, UK
| |
Collapse
|