Surgery Followed by Intracavitary plus Systemic Chemotherapy in Malignant Pleural Mesothelioma

Aims and background

Malignant mesothelioma is associated with a median survival of 4 to 12 months. Data from the literature indicate that single modality treatment (surgery or intrapleural and/or systemic chemotherapy) does not significantly affect survival.

Methods

We therefore evaluated a combined approach consisting of surgery (pleurectomy + diaphragmatic or pericardial resection), intrapleural chemotherapy with cisplatin (100 mg/m2) and cytarabine (1,000 mg/m2) for 4 h immediately after pleurectomy, and systemic chemotherapy consisting of epirubicin (60 mg/m2) and mitomycin-C (10 mg/m2) day 1 every 4 weeks for 4 cycles.

Results

Twenty patients were enrolled in the study and were evaluable. Thirteen cases had residual gross disease after pleurectomy and 7 patients only minimal disease. Median time to disease progression was 7.4 months, and median survival was 11.5 months (range, 2-25+). No treatment-related death have been observed. Side effects after intracavitary chemotherapy included renal toxicity, anaemia and pain. Myelosuppression and alopecia were recorded during systemic chemotherapy.

Conclusions

The results of the study indicate that the schedule is feasible, with encouraging results in terms of survival for patients with minimal residual disease after surgery.

In vivo and in vitro evidence that intrinsic upper- and lower-limb skeletal muscle function is unaffected by ageing and disuse in oldest-old humans

AIM

To parse out the impact of advanced ageing and disuse on skeletal muscle function, we utilized both in vivo and in vitro techniques to comprehensively assess upper- and lower-limb muscle contractile properties in 8 young (YG; 25 ± 6 years) and 8 oldest-old mobile (OM; 87 ± 5 years) and 8 immobile (OI; 88 ± 4 years) women.

METHODS

In vivo, maximal voluntary contraction (MVC), electrically evoked resting twitch force (RT), and physiological cross-sectional area (PCSA) of the quadriceps and elbow flexors were assessed. Muscle biopsies of the vastus lateralis and biceps brachii facilitated the in vitro assessment of single fibre-specific tension (Po).

RESULTS

In vivo, compared to the young, both the OM and OI exhibited a more pronounced loss of MVC in the lower limb [OM (-60%) and OI (-75%)] than the upper limb (OM = -51%; OI = -47%). Taking into account the reduction in muscle PCSA (OM = -10%; OI = -18%), only evident in the lower limb, by calculating voluntary muscle-specific force, the lower limb of the OI (-40%) was more compromised than the OM (-13%). However, in vivo, RT in both upper and lower limbs (approx. 9.8 N m cm(-2) ) and Po (approx. 123 mN mm(-2) ), assessed in vitro, implies preserved intrinsic contractile function in all muscles of the oldest-old and were well correlated (r = 0.81).

CONCLUSION

These findings suggest that in the oldest-old, neither advanced ageing nor disuse, per se, impacts intrinsic skeletal muscle function, as assessed in vitro. However, in vivo, muscle function is attenuated by age and exacerbated by disuse, implicating factors other than skeletal muscle, such as neuromuscular control, in this diminution of function.

Highly transparent poly(2-ethyl-2-oxazoline)-TiO2 nanocomposite coatings for the conservation of matte painted artworks

A nanocomposite coating based on TiO₂ nanoparticles and poly(2-ethyl-2-oxazoline) is used as consolidant of matte paintings (such as temperas), by exploiting bulk scattering phenomenon to mimic the surface diffusive properties of the painted surface.

Deletion of small ankyrin 1 (sAnk1) isoforms results in structural and functional alterations in aging skeletal muscle fibers

Muscle-specific ankyrins 1 (sAnk1) are a group of small ankyrin 1 isoforms, of which sAnk1.5 is the most abundant. sAnk1 are localized in the sarcoplasmic reticulum (SR) membrane from where they interact with obscurin, a myofibrillar protein. This interaction appears to contribute to stabilize the SR close to the myofibrils. Here we report the structural and functional characterization of skeletal muscles from sAnk1 knockout mice (KO). Deletion of sAnk1 did not change the expression and localization of SR proteins in 4- to 6-mo-old sAnk1 KO mice. Structurally, the main modification observed in skeletal muscles of adult sAnk1 KO mice (4-6 mo of age) was the reduction of SR volume at the sarcomere A band level. With increasing age (at 12-15 mo of age) extensor digitorum longus (EDL) skeletal muscles of sAnk1 KO mice develop prematurely large tubular aggregates, whereas diaphragm undergoes significant structural damage. Parallel functional studies revealed specific changes in the contractile performance of muscles from sAnk1 KO mice and a reduced exercise tolerance in an endurance test on treadmill compared with control mice. Moreover, reduced Qγ charge and L-type Ca(2+) current, which are indexes of affected excitation-contraction coupling, were observed in diaphragm fibers from 12- to 15-mo-old mice, but not in other skeletal muscles from sAnk1 KO mice. Altogether, these findings show that the ablation of sAnk1, by altering the organization of the SR, renders skeletal muscles susceptible to undergo structural and functional alterations more evident with age, and point to an important contribution of sAnk1 to the maintenance of the longitudinal SR architecture.

Degradation of nitrocellulose-based paint by Desulfovibrio desulfuricans ATCC 13541

Nitrocellulose is one of the most commonly used compounds in ammunition and paint industries and its recalcitrance to degradation has a negative impact on human health and the environment. In this study the capability of Desulfovibrio desulfuricans ATCC 13541 to degrade nitrocellulose as binder in paint was assayed for the first time. Nitrocellulose-based paint degradation was followed by monitoring the variation in nitrate, nitrite and ammonium content in the culture medium using Ultraviolet-Visible spectroscopy. At the same time cell counts and ATP assay were performed to estimate bacterial density and activity in all samples. Infrared spectroscopy and colorimetric measurements of paint samples were performed to assess chemical and colour changes due to the microbial action. Microscope observations of nitrocellulose-based paint samples demonstrated the capability of the bacterium to adhere to the paint surface and change the paint adhesive characteristics. Finally, preliminary studies of nitrocellulose degradation pathway were conducted by assaying nitrate- and nitrite reductases activity in D. desulfuricans grown in presence or in absence of paint. We found that D. desulfuricans ATCC 13541 is able to transform nitrocellulose as paint binder and we hypothesised ammonification as degradation pathway. The results suggest that D. desulfuricans ATCC 13541 is a good candidate as a nitrocellulose-degrading bacterium.

Nutrition and acne: therapeutic potential of ketogenic diets

The influence of nutrition on skin health is a growing research area but the findings of various studies on the effect of diet on the development of acne have often been contradictory. The general opinion among researchers has oscillated between two different, opposing positions: that diet either is or is not a key factor for acne development. This review examines the evidence supporting an influence of various dietary components on the development of acne particularly focusing on the role played by carbohydrates. The physiological and biochemical effects of the ketogenic diet are examined from this perspective and mechanisms will be proposed via which this type of diet could have a role in the treatment of acne.

Improved V̇O2 uptake kinetics and shift in muscle fiber type in high-altitude trekkers

The study investigated the effect of prolonged hypoxia on central [i.e., cardiovascular oxygen delivery (Q̇aO2)] and peripheral (i.e., O2 utilization) determinants of oxidative metabolism response during exercise in humans. To this aim, seven male mountaineers were examined before and immediately after the Himalayan Expedition Interamnia 8000–Manaslu 2008, lasting 43 days, among which, 23 days were above 5,000 m. The subjects showed a decrease in body weight ( P < 0.05) and of power output during a Wingate Anaerobic test ( P < 0.05) and an increase of thigh cross-sectional area ( P < 0.05). Absolute maximal O2 uptake (V̇O2max) did not change. The mean response time of V̇O2 kinetics at the onset of step submaximal cycling exercise was reduced significantly from 53.8 s ± 10.9 to 39.8 s ± 10.9 ( P < 0.05), whereas that of Q̇aO2 was not. Analysis of single fibers dissected from vastus lateralis biopsies revealed that the expression of slow isoforms of both heavy and light myosin subunits increased, whereas that of fast isoforms decreased. Unloaded shortening velocity of fibers was decreased significantly. In summary, independent findings converge in indicating that adaptation to chronic hypoxia brings about a fast-to-slow transition of muscle fibers, resulting in a faster activation of the mitochondrial oxidative metabolism. These results indicate that a prolonged and active sojourn in hypoxia may induce muscular ultrastructural and functional changes similar to those observed after aerobic training.

Cellular and molecular responses of human skeletal muscle exposed to hypoxic environment

The effects of a hypobaric, hypoxic environment and exercise performed under extreme conditions, such as at high altitudes, are intriguing physiological aspects that need to be investigated directly on human climbers. Their skeletal muscle is one of the main tissues that can suffer from hypoxia and physical challenges, which will both define the muscle adaptation and the molecular signature of regenerative capacity. We investigated the muscle regenerative capacity characterizing satellite cells. Our study shows that satellite cells are altered by hypobaric, hypoxic environments and exercise performed at high altitudes. Of note, in human skeletal muscle after this 5,000 m a.s.l. expedition, SCs showed a significantly lower ability to regenerate skeletal muscle, in respect to before this high-altitude expedition. This impairment appears to be due to reduced satellite cell activity, consistent with their decreased myogenicity and fusion ability. Furthermore, at the transcriptional level several pathways, such as cell cycle, myogenesis, oxidative metabolism, proteolysis and sarcomeric protein synthesis, were found dysregulated.

Characterization of fresh and aged natural ingredients used in historical ointments by molecular spectroscopic techniques: IR, Raman and fluorescence

Natural organic materials used to prepare pharmaceutical mixtures including ointments and balsams have been characterized by a combined non-destructive spectroscopic analytical approach. Three classes of materials which include vegetable oils (olive, almond and palm tree), gums (Arabic and Tragacanth) and beeswax are considered in this study according to their widespread use reported in ancient recipes. Micro-FTIR, micro-Raman and fluorescence spectroscopies have been applied to fresh and mildly thermally aged samples. Vibrational characterization of these organic compounds is reported together with tabulated frequencies, highlighting all spectral features and changes in spectra which occur following artificial aging. Synchronous fluorescence spectroscopy has been shown to be particularly useful for the assessment of changes in oils after aging; spectral difference between Tragacanth and Arabic gum could be due to variations in origin and processing of raw materials. Analysis of these materials using non-destructive spectroscopic techniques provided important analytical information which could be used to guide further study.

Partially fluorinated acrylic copolymers as coatings for stone protection: characterization and surface properties

In the last decades the conservation and protection of historical buildings, after theincreased atmospheric pollution, became a priority in all industrial countries. The natural stones exposed to a dramatically increased aggressive environment show their durability limits. The necessity to study new protective systems specifically projected to defend the materials according to the peculiar characteristics of each stone substrate. The complex heterogeneity of stone substrates demands an adaptable and efficient shielding strategy in order to satisfy the different protection requirements such as water repellency, permeability, photochemical and thermal stability and transparency. These characteristics, obviously, have to be maintained as long as possible. Such modulated multi-response behaviors can only be attempted with materials based on multifunctional copolymers. Different polymeric materials have been employed as coatings for building materials but these products were always transferred from industrial applications to the conservation of Cultural Heritage without a deep knowledge of their properties and without a real optimization of structures for stone protection.

[The ketogenic diet: an underappreciated therapeutic option?]

Obesity is reaching epidemic proportions in Western countries and is a strong risk factor for cardiovascular disease. Despite the constant recommendations of health care organizations regarding the importance of weight control, this goal often fails. Although there is a common agreement about the concept that exercise and diet are two key factors for the control of body weight, the ideal amount and type of exercise and also the ideal diet for weight control are still under debate. A widely accepted nutritional regime is the Mediterranean diet that has evident health benefits although less attention has been paid to see if the effects are due to other lifestyle factors which may contribute to the health benefits perhaps as much as specific food choices. There are several other options available to the physician that may produce good weight loss results in the short/medium term and also for maintenance of the goal achieved. One of these strategies is the ketogenic diet or VLCKD (very low carbohydrate ketogenic diet) that has been widely studied in recent years. Most studies show that this diet has a solid physiological and biochemical basis which is able to induce effective weight loss and improvement of several parameters of cardiovascular risk. This review discusses the physiological basis of VLCKD and the main applications together with its strengths and weaknesses compared to common dietary recommendations.

Transcription profile analysis of vastus lateralis muscle from patients with chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a disabling condition characterized by unexplained chronic fatigue that impairs normal activities. Many body systems are affected and etiology has not yet been identified. In addition to immunological and psychological aspects, skeletal muscle symptoms are prominent in CFS patients. In an effort to establish which pathways might be involved in the onset and development of muscle symptoms, we used global transcriptome analysis to identify genes that were differentially expressed in the vastus lateralis muscle of female and male CFS patients. We found that the expression of genes that play key roles in mitochondrial function and oxidative balance, including superoxide dismutase 2, were altered, as were genes involved in energy production, muscular trophism and fiber phenotype determination. Importantly, the expression of a gene encoding a component of the nicotinic cholinergic receptor binding site was reduced, suggesting impaired neuromuscular transmission. We argue that these major biological processes could be involved in and/or responsible for the muscle symptoms of CFS.

Functional characterization of muscle fibres from patients with chronic fatigue syndrome: case-control study

Chronic fatigue syndrome (CFS) is a disabling condition characterized by unexplained chronic fatigue that impairs normal activities. Although immunological and psychological aspects are present, symptoms related to skeletal muscles, such as muscle soreness, fatigability and increased lactate accumulation, are prominent in CFS patients. In this case-control study, the phenotype of the same biopsy samples was analyzed by determining i) fibre-type proportion using myosin isoforms as fibre type molecular marker and gel electrophoresis as a tool to separate and quantify myosin isoforms, and ii) contractile properties of manually dissected, chemically made permeable and calcium-activated single muscle fibres. The results showed that fibre-type proportion was significantly altered in CSF samples, which showed a shift from the slow- to the fast-twitch phenotype. Cross sectional area, force, maximum shortening velocity and calcium sensitivity were not significantly changed in single muscle fibres from CSF samples. Thus, the contractile properties of muscle fibres were preserved but their proportion was changed, with an increase in the more fatigue-prone, energetically expensive fast fibre type. Taken together, these results support the view that muscle tissue is directly involved in the pathogenesis of CSF and it might contribute to the early onset of fatigue typical of the skeletal muscles of CFS patients.

Polyketone polymer: a new support for direct enzyme immobilization

Polyketone polymer -[-CO-CH(2)-CH(2)-](n)-, obtained by copolymerization of ethene and carbon monoxide, is utilized for immobilization of three different enzymes, one peroxidase from horseradish (HRP) and two amine oxidases, from bovine serum (BSAO) and lentil seedlings (LSAO). The easy immobilization procedure is carried out in diluted buffer, at pH 7.0 and 3 degrees C, gently mixing the proteins with the polymer. No bifunctional reagents and spacer arms are required for the immobilization, which occurs exclusively via a large number of hydrogen bonds between the carbonyl groups of the polymer and the -NH groups of the polypeptidic chain. Experiments demonstrate a high linking capacity of polymer for BSAO and an extraordinary strong linkage for LSAO. Moreover, activity measurements demonstrate that immobilized LSAO totally retains the catalytic characteristics of the free enzyme, where only a limited increase of K(M) value is observed. Finally, the HRP-activated polymer is successfully used as active packed bed of an enzymatic reactor for continuous flow conversion and flow injection analysis of hydrogen peroxide containing solutions.

Expression of eight distinct MHC isoforms in bovine striated muscles: evidence for MHC-2B presence only in extraocular muscles

This study aimed to analyse the expression of myosin heavy chain (MHC) isoforms in bovine muscles, with particular attention to the MHC-2B gene. Diaphragm, longissimus dorsi, masseter, several laryngeal muscles and two extraocular muscles (rectus lateralis and retractor bulbi) were sampled in adult male Bos taurus (age 18-24 months, mass 400-500 kg) and analysed by RT-PCR, gel electrophoresis and immunohistochemistry. Transcripts and proteins corresponding to eight MHC isoforms were identified: MHC-alpha and MHC-beta/slow (or MHC-1), two developmental isoforms (MHC-embryonic and MHC-neonatal), three adult fast isoforms (MHC-2A, MHC-2X and MHC-2B) and the extraocular isoform MHC-Eo. All eight MHC isoforms were found to be co-expressed in extrinsic eye muscles, retractor bulbi and rectus lateralis, four (beta/slow, 2A, 2X, neonatal) in laryngeal muscles, three (beta/slow, 2A and 2X) in trunk and limb muscles and two (beta/slow and alpha) in masseter. The expression of MHC-2B and MHC-Eo was restricted to extraocular muscles. Developmental MHC isoforms (neonatal and embryonic) were only found in specialized muscles in the larynx and in the eye. MHC-alpha was only found in extraocular and masseter muscle. Single fibres dissected from masseter, diaphragm and longissimus were classified into five groups (expressing, respectively, beta/slow, alpha, slow and 2A, 2A and 2X) on the basis of MHC isoform electrophoretical separation, and their contractile properties [maximum shortening velocity (v(0)) and isometric tension (P(0))] were determined. v(0) increased progressively from slow to fast 2A and fast 2X, whereas hybrid 1-2A fibres and fibres containing MHC-alpha were intermediate between slow and fast 2A.

Myosin heavy chain 2B isoform is expressed in specialized eye muscles but not in trunk and limb muscles of cattle

Myosin heavy chain isoforms (MHC) of adult skeletal muscles are codified by four genes named: slow, or type 1, and fast types 2A, 2X and 2B. The slow, 2A and 2X isoforms have been found expressed in all mammalian species studied so far whereas there is a large inter-species variability in the expression of MHC-2B. In this study histochemistry (m-ATPase), immunohistochemistry with the use of specific monoclonal antibodies and RT-PCR were combined together to assess whether the MHC-2B gene is expressed in bovine muscles. ATPase staining and RT-PCR experiments showed that three MHC isoforms (1, 2A, 2X) were expressed in trunk and limb muscles. Slow or type 1 expression was confirmed using a specific antibody (BA-F8) whereas the detection of fast MHC isoforms were validate by means of BF-35 antibody although not by the SC-71 antibody. MHC-2B was absent in limb and trunk muscles, but was present in specialized eye muscles (rectus lateralis and retractor bulbi) as consistently showed by RT-PCR and reactivity with a specific antibody (BF-F3). Interestingly, a cardiac isoform, MHC-a-cardiac was found to be expressed not only in extraocular muscles but also in masticatory muscles as masseter.

Evaluation of barium hydroxide treatment efficacy on a dolomitic marble

The Arch of Peace, by Luigi Cagnola, is one of the most famous neoclassical monuments in Milan. It has been subjected to conservative intervention in 1998. In the present paper the efficacy of the consolidation by means of barium hydroxide has been evaluated. The stone material showed severe degradation phenomena as: erosion, pulverisation, exfoliation. The analytical data acquired through X-ray diffraction (XRD), infrared spectrophotometry (FTIR) and scanning electron microscopy (SEM-EDX), allowed to compare the conditions of stone before and after the treatment with barium hydroxide. The presence of barium has been put in evidence mainly on the surface as barium sulphate, whereas barium is only sporadically present within the thickness of the decayed material. The treatment was judged not satisfying and its inefficacy is, most probably, due to a not suitable cleaning procedure carried out before the consolidation.

A key factor in modern protection of historic buildings: the assessment of penetration of water-repellent polymers into porous stone-materials

From the 1960s on, the conservation of monuments and stone masonry has witnessed an increasing use of polymeric products during restoration interventions. Actual penetration depths reached by different polymers within the porous stone matrix are supposed to be key factors in determining the efficacy of the treatments themselves (besides, of course, the chemical-mineralogical nature of the stone and the chemical-physical characteristics of the various polymers). This work presents some preliminary results obtained on specimens of Noto calcarenite treated with various polymeric protective products. Samples were investigated with direct analytical methods (micro-ATR spectroscopy, SEM) in order to assess penetration depths reached by polymers inside the stone while reducing to a minimum the necessary manipulation of specimens. The obtained results highlighted the following trend in penetration depths for the various products tested: siloxane product > partially fluorinated acrylic resin > acrylic resin. Moreover, data obtained allowed to establish direct correlation between long term efficacy of products and relative penetration depths.

Effect of fluorinated groups on photooxidative stability of polymeric protectives applied on marble

Some new protective copolymers and a commercial one have been tested on Candoglia marble, a very low porosity stone. Two of the polymers contained a partially fluorinated methacrylic monomer, 2,2,2 trifluoro ethyl methacrylate (TFEMA), in combination with either an acrylic, methyl acrylate (MA) or a vinyl ether, n-butyl vinyl ether (n-BVE) unit. Two copolymers, ethyl methacrylate/n-butyl vinyl ether and ethyl methacrylate (EMA)/methyl acrylate (Paraloid B72), were non-fluorinated and similar in compositions and molar ratio. The aim of the work is to test the copolymers and compare the performances of fluorinated new polymers with the non fluorinated one and with the largely used commercial product. The results obtained demonstrate that the introduction, even in limited amounts, of fluorine atoms in the side ester groups of methacrylic type polymers really improves their protective effect and the durability of the stone treatments. The best results were obtained with the copolymer TFEM/MA which is the fluorinated homologous of Paraloid B72.

Atypical coloration of plaster in renaissance frescoes

The Baptistery of Castiglione Olona (Varese, Italy), frescoed by Masolino da Panicale at the beginning of the 14th Century, is currently under restoration. On this occasion its state of preservation was investigated, in order to plan a correct intervention. During the sampling, an interesting phenomenon was pointed out, i.e. a wide rose coloration on the plasters of the interior northern and western walls. In order to clarify the nature of the alteration, a sampling was undertaken both for a chemical-mineralogical characterization of plasters (XRD, SEM-EDX, FTIR) and to detect the presence of biodeteriogens.

A dose-escalating study of carboplatin combined with vinorelbine in non-small-cell lung cancer

Platinum compounds and vinorelbine have been demonstrated to be active in non-small-cell lung cancer (NSCLC). The aims of the study were to assess tolerability and feasibility of increasing doses of carboplatin (level 1: 300 mg/ m2 on day 1, level 2: 350 mg/m2 on day 1, level 3: 400 mg/m2 on day 1) in combination with a fixed dose of vinorelbine (25 mg/m2 on days 1 and 8) in advanced NSCLC. Forty-two patients entered the study and were evaluable for toxicity and response. The patients were not treated using systemic chemotherapy, had TNM stage IIIB-IV, performance status ECOG 0-2, and their median age was 62 (range 41-70) years. The number of patients evaluable for each dose level was 14. A total of 138 (median 3) courses was administered. Nonhematologic side effects included grade I-II mucositis (9%), neurotoxicity (6%), and infections (4%). Myelotoxicity was manageable and generally of short duration, with 19% of the patients having grade III-IV neutropenia. No significant difference was observed for the three treatment groups. No drug-related death was observed. An objective remission was observed in 10 patients (24% response rate; 95% confidence interval 12-39%), with 5 responses in 14 patients treated with the 400-mg/m2 dose. In conclusion, the combination of carboplatin at a dose of 400 mg/m2 on day 1 and vinorelbine at a dose of 25 mg/m2 on days 1 and 8 can be safely administered as first-line cytotoxic therapy in advanced NSCLC and warrants further evaluation.

Pleurectomy, intrapleural cisplatin and interferon followed by systemic carboplatin plus interferon in malignant pleural mesothelioma

Malignant pleural mesothelioma has a dismal prognosis and median survival rarely exceeds 12 months. Since multimodality therapy initially showed promising results, we tested the feasibility of a new approach consisting of pleurectomy, immediately followed by intrapleural chemotherapy with cisplatin (100 mg/m(2) day 1) and alpha-interferon (12x10(6) U/m(2) days 1 and 2), followed by 4 cycles of carboplatin, 350 mg/m(2), repeated every 3 weeks and associated to alpha-interferon (3x10(6) U/x3/week). Fourteen patients have been submitted to the protocol and are evaluable for side effects. All patients had surgery and intrapleural chemotherapy, and 4 patients also had systemic chemotherapy. No treatment-related deaths have been observed. Major postoperative complications included chest tube air leak >7 days (1 pt). Intracavitary chemo-immunotherapy-related toxicity was responsible for 7 cases of grade I nephro-toxicity and 2 cases of grade I fever. Grade I-II toxicity from systemic chemotherapy included asthenia (2 cases), fever (3 cases), anemia (2 cases) and neutropenia (2 cases). Grade III-IV toxicity included asthenia (1 case), anemia (2 cases), neutropenia (2 cases) and fever (1 case). Two cases required interruption of systemic chemotherapy for intolerance. Based on these data, systemic chemotherapy has been stopped. In conclusion, our results indicate that pleurectomy plus intra-cavitary cisplatin and interferon is feasible. Since systemic chemotherapy is correlated with severe side effects, a phase II trial with surgery plus intrapleural treatment alone is ongoing.