Open lung-sparing surgery for malignant pleural mesothelioma: the benefits of a radical approach within multimodality therapy.

OBJECTIVE: To identify the optimal debulking procedure in patients with malignant pleural mesothelioma who are not suitable for extrapleural pneumonectomy (EPP).

METHODS: We reviewed 102 consecutive patients (93 male; 9 female, mean age 63 years) who were not suitable for EPP because of either advanced tumour stage or suboptimal fitness. Patients underwent either a non-radical tumour decortication to obtain lung expansion (group NR) or latterly a radical pleurectomy/decortication to obtain macroscopic tumour clearance (group R). We analysed the comparative perioperative courses and long-term survival.

RESULTS: The two groups were similar for age and gender distribution but epithelioid type was more predominant in group R: 78% compared to 55% epithelioid in group NR. Thirty-day mortality was similar (5.9% in group R and 9.8% in the group NR, p=0.36) but 90-day mortality was significantly higher in the group NR (29.4% vs 9.8% in group R, p=0.012). More patients in group R received adjuvant chemotherapy (65% vs 28%, p=0.000) and radiotherapy (65% vs 26%, p=0.000). Median survival for all cell types was significantly higher in group R (15.3 months vs 7.1 months, p<0.000). Group R survival rates at 1, 2, 3 and 4 years were 53, 41, 25 and 13%, respectively while for group NR they were 32, 9.6, 2 and 0%, respectively. For epithelioid cell type there was still a significant median survival advantage in group R (25.4 months vs 10.2 months, p<0.000), but there was no difference for sarcomatoid (9.3 months vs 3.2 months, p=0.16) or biphasic cell types (9.4 months vs 7 months, p=0.38).

CONCLUSION: If a patient with epithelioid MPM is fit enough to tolerate a thoracotomy then macroscopic clearance of the tumour is the preferred option as part of a multimodality regime including chemotherapy.