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Extrapleural pneumonectomy for diffuse, malignant mesothelioma
UPDATE
_
As Originally Published in 1986:
Extrapleural Pneumonectomy for Diffuse, Malignant Mesothelioma Michael J. DaValle, M.D., L. Penfield Faber, M.D., C. Frederick Kittle, M.D., and Robert J. [ensik, M.D. ABSTRACT Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24
months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative com plications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional longterm survivor.
Updated in 1994 by 1. Penfield Faber, MD Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
h e exact role of extrapleural pneumonectomy for malignant mesothelioma was controversial in 1986 [1] and it remains controversial in 1994. Criticism is directed toward the procedure's high operative mortality and morbidity rate, which may not be justified by a statistically significant survival advantage. Current series identify 2-year survival rates from 10% to 48% and 5-year survival rates of 10%. Median survival is reported to be from 10 to 16 months [2-4]. Refinement in surgical and anesthetic techniques with improvement in postoperative care have reduced mortality rates to 5% or 7% [2, 3]. Despite the decrease in operative mortality and morbidity in the past 7 years, a question remains regarding its efficacy with respect to long-term survival. Ongoing analysis of our results have led us to become more selective in the indications for this procedure. Extrapleural pneumonectomy is recommended to patients who are good physiologic risks and have stage I disease. All therapeutic options in the fatal course of this malignancy always are explained carefully to the patient to permit a well-informed decision. When pleurectomy is the intended surgical procedure, the lung parenchyma and major fissure can be invaded deeply by the tumor; in this instance, extrapleural pneumonectomy is carried out dependent on the patient's ability to withstand the procedure. Our series now consists of 40 patients who have un-
T
Address reprint requests to Dr Faber, 1725 West Harrison, Rm 218, Chicago, IL 60612. © 1994 by The Society of Thoracic Surgeons
dergone extrapleural pneumonectomy. Histologic classification is epithelial in 65% (26/40), mixed in 2S% (10/40), and sarcomatous in 10% (4/40). Adjuvant therapy consisting of chemotherapy, radiation, or both was given to 78% (31/40). Mortality and morbidity for patients undergoing extrapleural pneumonectomy are 7.5% (3/40) and 30% (12/40), respectively. The 1-, 2-, and 4-year survival rates are 53%, 23%, and 13%, with a median survival of 13.3 months (range, 1.5 to 82 months). Cox regression analysis did identify that sarcomatous histology and lack of any postoperative adjuvant therapy adversely affected survival. Another recent series has reported the benefits of postoperative chemotherapy and radiation after extrapleural pneumonectomy [3]. The overall median survival was 16 months (range, 1 month to 8 years), but patients with epithelial histology had a 2-year survival rate of 50%. A significant point in this report was that 25 patients with epithelial-type tumors and negative mediastinal nodes had a projected survival rate of 45°~) at 5 years. The Lung Cancer Study Group, in a prospective but not randomized trial, compared extrapleural pneumonectomy without postoperative adjuvant therapy with either pleurectomy or no further surgical intervention [4]. The mortality rate for the extrapleural pneumonectomy group was 15%, with a median survival of 10 months. It was concluded that extrapleural pneumonectomy carried a significant operative mortality and did not improve overall survival compared with more conservative forms of treatment. Referral of patients to specialized treatment centers with an interest in malignant mesothelioma will allow Ann Thorac Surg 1994;58:1782-3
•
0003-4975/94/$7.00
UPDATE FABER EXTRAPLEURAL PNEUMONECTOMY
Ann Thorac Surg 1994;58:1782-3
evaluation of multimodality regimens incorporating cytoreductive operation, chemotherapy, and irradiation. Extrapleural pneumonectomy should be considered for patients in whom pleurectomy technically is impossible due to invasion of the lung by tumor or in whom complete resection of all gross disease is feasible in stage I disease, giving consideration to the patient's overall general medical condition. A more precise system of staging, which currently is under development, may permit improved patient selection with longer survival. The patient with the least amount of disease may be the one who would benefit most from extrapleural pneumonectomy.
1783
References 1. DaValle MJ, Faber LP, Kittle CF, Jensik RJ. Extrapleural pneumonectomy for diffuse, malignant mesothelioma. Ann Thorac 5urg 1986;42:612-8. 2. Allen KB, Faber LP, Warren WH. Malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy. Chest 5urg Clin North Am 1994;4:113-26. 3. 5ugarbaker DJ, Strauss GM, Lynch TJ, et al. Node status has prognostic significance in the multimodality therapy of diffuse, malignant mesothelioma. J Clin Oncol 1993;11: 1172-8. 4. Rusch VW. Pleurectomy/decortication and adjuvant therapy for malignant mesothelioma. Chest 1993;103:3825-45.
REVIEW OF RECENT BOOKS Atlas of Thoracoscopic Surgery Mark]. Krasna, MD, and Michael J. Mack, MD St. Louis, Quality Medical Publishing, Inc, 1994 216 pp, illustrated, $175.00
Reviewed by Thomas W. Rice, MD The introduction of the miniature videocamera has allowed excellent visualization during thoracoscopy and has renewed interest in this old procedure. Not unexpectedly there has been a flurry of textbooks on this subject. The questions arise whether the Atlas of Thoracoscopic Surgery, which is not the first of its kind, is needed, and whether it is better than similar textbooks presently available. Do not be inhibited from reading beyond the preface, where the unsubstantiated claims of video-assisted thoracic surgery are outlined, including an erroneous and misleading statement "minimally invasive procedures are more likely to protect health care personnel from exposure to infectious entities such as HIV and hepatitis." The text delivers as promised, "in clear, descriptive terms the techniques used to perform thoracoscopy at the University of Maryland Medical Center in Baltimore and the Medical City Dallas Hospital in Dallas." As expected of any thoracoscopy atlas the intraoperative photographs are excellent.
The accompanying color illustrations further clarify the text and pictures. The atlas effectively covers the range of general thoracic surgery but is rather unimaginative in the section on "newer applications of thoracoscopy." The major problem with video-assisted thoracic surgery is that the procedure has not undergone the critical evaluation and long-term follow-up necessary to determine its place in the general thoracic surgeon's armamentarium. The recent thoracoscopy literature is littered with case reports, personal opinion, and retrospective registry data, adding further confusion to the role video-assisted thoracic surgery is to play in the diagnosis and treatment of thoracic disease. The most beneficial portion of this atlas is the commentary by invited authors at the end of each chapter. For the practicing surgeon and the student these commentaries place the enthusiasm of the authors into proper perspective by pointing out the benefits and shortcomings of and the alternatives to thoracoscopic procedures. Indeed, this balanced view is extremely important and it is this type of format that aids the evolution of video-assisted thoracic surgery. This textbook is a valuable addition to the literature. Its balanced presentation, the result of invited commentaries, differentiates it from other thoracoscopic texts.
Cleveland, Ohio
_
As Originally Published in 1986:
Extrapleural Pneumonectomy for Diffuse, Malignant Mesothelioma Michael J. DaValle, M.D., L. Penfield Faber, M.D., C. Frederick Kittle, M.D., and Robert J. [ensik, M.D. ABSTRACT Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24
months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative com plications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional longterm survivor.
Updated in 1994 by 1. Penfield Faber, MD Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
h e exact role of extrapleural pneumonectomy for malignant mesothelioma was controversial in 1986 [1] and it remains controversial in 1994. Criticism is directed toward the procedure's high operative mortality and morbidity rate, which may not be justified by a statistically significant survival advantage. Current series identify 2-year survival rates from 10% to 48% and 5-year survival rates of 10%. Median survival is reported to be from 10 to 16 months [2-4]. Refinement in surgical and anesthetic techniques with improvement in postoperative care have reduced mortality rates to 5% or 7% [2, 3]. Despite the decrease in operative mortality and morbidity in the past 7 years, a question remains regarding its efficacy with respect to long-term survival. Ongoing analysis of our results have led us to become more selective in the indications for this procedure. Extrapleural pneumonectomy is recommended to patients who are good physiologic risks and have stage I disease. All therapeutic options in the fatal course of this malignancy always are explained carefully to the patient to permit a well-informed decision. When pleurectomy is the intended surgical procedure, the lung parenchyma and major fissure can be invaded deeply by the tumor; in this instance, extrapleural pneumonectomy is carried out dependent on the patient's ability to withstand the procedure. Our series now consists of 40 patients who have un-
T
Address reprint requests to Dr Faber, 1725 West Harrison, Rm 218, Chicago, IL 60612. © 1994 by The Society of Thoracic Surgeons
dergone extrapleural pneumonectomy. Histologic classification is epithelial in 65% (26/40), mixed in 2S% (10/40), and sarcomatous in 10% (4/40). Adjuvant therapy consisting of chemotherapy, radiation, or both was given to 78% (31/40). Mortality and morbidity for patients undergoing extrapleural pneumonectomy are 7.5% (3/40) and 30% (12/40), respectively. The 1-, 2-, and 4-year survival rates are 53%, 23%, and 13%, with a median survival of 13.3 months (range, 1.5 to 82 months). Cox regression analysis did identify that sarcomatous histology and lack of any postoperative adjuvant therapy adversely affected survival. Another recent series has reported the benefits of postoperative chemotherapy and radiation after extrapleural pneumonectomy [3]. The overall median survival was 16 months (range, 1 month to 8 years), but patients with epithelial histology had a 2-year survival rate of 50%. A significant point in this report was that 25 patients with epithelial-type tumors and negative mediastinal nodes had a projected survival rate of 45°~) at 5 years. The Lung Cancer Study Group, in a prospective but not randomized trial, compared extrapleural pneumonectomy without postoperative adjuvant therapy with either pleurectomy or no further surgical intervention [4]. The mortality rate for the extrapleural pneumonectomy group was 15%, with a median survival of 10 months. It was concluded that extrapleural pneumonectomy carried a significant operative mortality and did not improve overall survival compared with more conservative forms of treatment. Referral of patients to specialized treatment centers with an interest in malignant mesothelioma will allow Ann Thorac Surg 1994;58:1782-3
•
0003-4975/94/$7.00
UPDATE FABER EXTRAPLEURAL PNEUMONECTOMY
Ann Thorac Surg 1994;58:1782-3
evaluation of multimodality regimens incorporating cytoreductive operation, chemotherapy, and irradiation. Extrapleural pneumonectomy should be considered for patients in whom pleurectomy technically is impossible due to invasion of the lung by tumor or in whom complete resection of all gross disease is feasible in stage I disease, giving consideration to the patient's overall general medical condition. A more precise system of staging, which currently is under development, may permit improved patient selection with longer survival. The patient with the least amount of disease may be the one who would benefit most from extrapleural pneumonectomy.
1783
References 1. DaValle MJ, Faber LP, Kittle CF, Jensik RJ. Extrapleural pneumonectomy for diffuse, malignant mesothelioma. Ann Thorac 5urg 1986;42:612-8. 2. Allen KB, Faber LP, Warren WH. Malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy. Chest 5urg Clin North Am 1994;4:113-26. 3. 5ugarbaker DJ, Strauss GM, Lynch TJ, et al. Node status has prognostic significance in the multimodality therapy of diffuse, malignant mesothelioma. J Clin Oncol 1993;11: 1172-8. 4. Rusch VW. Pleurectomy/decortication and adjuvant therapy for malignant mesothelioma. Chest 1993;103:3825-45.
REVIEW OF RECENT BOOKS Atlas of Thoracoscopic Surgery Mark]. Krasna, MD, and Michael J. Mack, MD St. Louis, Quality Medical Publishing, Inc, 1994 216 pp, illustrated, $175.00
Reviewed by Thomas W. Rice, MD The introduction of the miniature videocamera has allowed excellent visualization during thoracoscopy and has renewed interest in this old procedure. Not unexpectedly there has been a flurry of textbooks on this subject. The questions arise whether the Atlas of Thoracoscopic Surgery, which is not the first of its kind, is needed, and whether it is better than similar textbooks presently available. Do not be inhibited from reading beyond the preface, where the unsubstantiated claims of video-assisted thoracic surgery are outlined, including an erroneous and misleading statement "minimally invasive procedures are more likely to protect health care personnel from exposure to infectious entities such as HIV and hepatitis." The text delivers as promised, "in clear, descriptive terms the techniques used to perform thoracoscopy at the University of Maryland Medical Center in Baltimore and the Medical City Dallas Hospital in Dallas." As expected of any thoracoscopy atlas the intraoperative photographs are excellent.
The accompanying color illustrations further clarify the text and pictures. The atlas effectively covers the range of general thoracic surgery but is rather unimaginative in the section on "newer applications of thoracoscopy." The major problem with video-assisted thoracic surgery is that the procedure has not undergone the critical evaluation and long-term follow-up necessary to determine its place in the general thoracic surgeon's armamentarium. The recent thoracoscopy literature is littered with case reports, personal opinion, and retrospective registry data, adding further confusion to the role video-assisted thoracic surgery is to play in the diagnosis and treatment of thoracic disease. The most beneficial portion of this atlas is the commentary by invited authors at the end of each chapter. For the practicing surgeon and the student these commentaries place the enthusiasm of the authors into proper perspective by pointing out the benefits and shortcomings of and the alternatives to thoracoscopic procedures. Indeed, this balanced view is extremely important and it is this type of format that aids the evolution of video-assisted thoracic surgery. This textbook is a valuable addition to the literature. Its balanced presentation, the result of invited commentaries, differentiates it from other thoracoscopic texts.
Cleveland, Ohio