Pleurectomy and decortication for malignant mesothelioma

Thorac Surg Clin 14 (2004) 517 – 521

Pleurectomy and decortication for malignant mesothelioma Scott W. Cowan, MDa, Taine T. Pechet, MDb,* b

a Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA Division of Thoracic Surgery, University of Pennsylvania Medical Center at Presbyterian, 51 North 39th Street, 266 Wright-Saunders, Philadelphia, PA 19104, USA

The incidence of diffuse malignant mesothelioma has increased over the past two decades, with approximately 2200 new cases arising annually in the United States. Accordingly, considerable progress has been made in earlier diagnosis, safer surgical resection, and the development of multimodality therapies aimed at the elimination of this disease. Despite these advances, the prognosis of malignant mesothelioma remains poor. Surgery is a cornerstone in the therapeutic approach to malignant mesothelioma. Pleurectomy/ decortication (P/D) and extrapleural pneumonectomy (EPP) are the primary surgical cytoreductive procedures currently available to combat this disease. Pleurectomy originally was developed as a palliative maneuver for controlling pleural fluid accumulation in patients with malignant mesothelioma [1,2], and it involves removal of the parietal pleural surface, diaphragm, and pericardium. Visceral decortication has been combined with pleurectomy for cytoreductive purposes and entails resection of the involved visceral pleural surface with preservation of lung parenchyma. In contrast, EPP involves en bloc resection of lung, parietal pleura, ipsilateral pericardium, and diaphragm. This article provides a description of the procedure and discusses the role of P/D in the treatment of malignant pleural mesothelioma (MPM).

* Corresponding author. E-mail address: [email protected] (T.T. Pechet).

Conduct of the operation: pleurectomy and decortication After the initiation of one-lung anesthesia, a posterolateral thoracotomy through the sixth or seventh interspace provides optimal exposure to the left or right thoracic cavities. If necessary, an incision through the tenth intercostal space may be added to provide access to the diaphragm and costophrenic angle posteriorly when resection is required. Resection of the seventh rib usually obviates this requirement. The incision is carried down through the intercostal muscles and the pleural space is entered. The first plane of dissection developed during the P/D procedure is between the lung and the tumor. The operative lung is kept on positive end-expiratory pressure (5 – 40 cm of water) during most of the decortication. Sharp dissection is used to separate the visceral pleura from the underlying parenchyma. Scalpel dissection can be helpful in developing this plane. Removal of segments of parenchymal tissue may be unavoidable because of local tumor deposits, and it often causes transient air leaks, which seal quickly after lung-chest wall apposition. Blunt dissection is then undertaken to develop the natural plane that exists between the pleura and the endothoracic fascia. Bleeding from the raw pleural surface can be significant and is controlled with local packing or argon beam coagulation. Fibrin glue, particularly the aerosolized versions, also may be helpful for controlling cavitary bleeding. Dissection continues to the apex of the thorax, inferiorly to the diaphragm, then anteriorly and posteriorly toward the hilum of the lung. Care is taken to avoid injury to

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the esophagus and the aortic intercostal vessels. In the right chest, injury to the superior vena cava, azygos vein, subclavian artery, or internal thoracic artery or vein can be avoided by careful dissection. En bloc resection of mediastinal nodes is routinely performed for staging purposes. The pleural surface of the diaphragm is removed by creating a plane of dissection in the muscular layer of the diaphragm. Advanced disease may necessitate complete resection of the diaphragm while preserving the continuity of the peritoneum. Avoiding entrance into the peritoneum is recommended to avoid the risk of inducing peritoneal implants. Resection of the diaphragm on the right side is frequently more demanding because of the location of the esophageal hiatus and inferior vena cava. Repair of the diaphragm is performed, when necessary, using a prosthetic impermeable 2-mm Gore-Tex patch (W.L. Gore and Associates, Inc., Flagstaff, Arizona). A plane between the mediastinal pleura and the pericardium exists but may be obliterated by local disease, necessitating full-thickness pericardial resection. Often it is possible to strip tumor from the mediastinum but preserve at least partial thickness of the pericardium. Defects of the right pericardium require repair to avoid the risk of cardiac herniation. Left pericardial repair is not required provided the entire pericardium is excised. We routinely repair the left pericardium using a Gore-Tex pericardial membrane to prevent this dreaded complication.

Indications and results P/D provides a lasting and effective palliative measure in patients with MPM. Symptomatic pleural effusions occur in 30% to 90% of these patients [3 – 5]. Tube thoracostomy and sclerosant therapy have a high failure rate for the management of these effusions, typically because of failure to achieve pleural apposition. Martini et al [1] treated 14 patients with MPM with P/D and observed no fluid reaccumulation. Brancatisano et al [6] performed a subtotal parietal pleurectomy in 45 of 50 patients combined with a decortication procedure in 28 patients. Only 1 patient had symptomatic pleural fluid reaccumulation. Soysal et al [7] performed pleurectomy in 100 patients with MPM and obtained pleural fluid control in 96% of them. In addition to preventing fluid reaccumulation, parietal pleurectomy improves thoracic wall function by increasing diaphragmatic and chest wall compliance. As a result, the increased thoracic cage expan-

sion relieves symptoms of cough, dyspnea, and chest pain [7]. Encasement of the lung with tumor limits pulmonary expansion and apposition of visceral to parietal pleura. Visceral pleurectomy permits pulmonary re-expansion and facilitates pleural symphysis. The role of P/D as a curative treatment option when used in conjunction with other therapies remains under active investigation. For early stage disease, P/D provides adequate tumor resection and seems to be an effective cytoreductive procedure. For advanced disease that involves encasement and infiltration of lung tissue, it is often impossible to resect all gross disease. In such cases, EPP provides better control. Martini et al [8] reported that in 20% of patients with malignant mesothelioma, P/D was not technically possible because of extensive visceral pleural invasion and an absent free pleural space. Sugarbaker et al [9] demonstrated that positive microscopic resection margins adversely affect long-term survival, which suggests that patients with advanced disease may benefit from a more radical cytoreductive surgery, such as EPP. Because P/D does not involve removal of the lung, however, it remains a valid treatment option in patients with MPM who have impaired lung function. Historically, P/D has been associated with decreased perioperative mortality in comparison with EPP. This disparity seems to be decreasing. P/D is associated with a surgical mortality rate of 1.5% to 5% [5,10], whereas the operative mortality rate after EPP has been reported to be as low as 3.8% in recent studies [11]. In a report by Rusch and Venkatraman [12], morbidities were reported in 13 of 51 patients who underwent P/D, including prolonged air leak (38%), empyema (31%), and atrial dysrhythmia (15%). Less common morbidities included pulmonary embolus, multisystemic failure, renal failure, and ventricular arrhythmias. A summary of outcomes after P/D is provided in Table 1.

Combination treatment options Efforts to eliminate residual disease and reduce local recurrence after P/D have included combinations of intraoperative and postoperative radiation, intrapleural and systemic chemotherapy, and phototherapy. Radiation as a treatment modality for MPM has been investigated extensively. McCormack et al [5] obtained a median survival of 12.6 months with P/D and postoperative radiation. Hilaris et al [13] combined P/D with intraoperative radioactive implants and postoperative hemithoracic external beam radiation to a total of 4500 cGy. In their study, the

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Table 1 Results of pleurectomy and decortication Survival Study

Adjuvant treatment

Brancatisano et al [6] Law et al [29] Chahinian et al [30] Ruffie et al [31] Soysal et al [7] Martini et al [8] McCormack et al [5]a

None

Rusch et al [16]b Lee et al [18] Faber [32] Alberts et al [33]

Radiation implants/ RT Radiation implants RT/ systemic chemotherapy Intrapleural chemotherapy/systemic chemotherapy Intrapleural chemotherapy/systemic chemotherapy:(n = 7)/RT (n = 11) +/ RT and chemotherapy RT/chemotherapy

No. patients

Morbidity (%)

Mortality (%)

1 year (%)

Median (mo)

45 28 30 63 100 94 33

16 NS NS NS 22 NS NS

2.2 NS 0 NS 1 0 NS

58 23 57 NS NS 44 NS

21 20 13 9.8 17 21 21

27

40

3.7

68

17

15

13

0

NS

11.5

35 26

NS NS

8.6 NS

NS NS

10 10.9

Abbreviations: NS, not specified; RT, radiotherapy (external beam). a Residual tumor implanted with iodine 125 at time of surgery or iridium 192 after surgery. b Complications of OR + chemotherapy.

median survival was 21 months, the 1-year survival rate was 65%, and the 2-year survival rate was 40%. Higher doses of radiation are associated with unacceptable toxicities, including decreased pulmonary function in the irradiated lung and adjacent organ injury [14,15]. Combining P/D with adjuvant systemic chemotherapy and radiation has had minimal success. Allen et al [10] reported on 96 patients who underwent either P/D (56 patients) or EPP (40 patients). Most patients in the study were treated additionally with adjuvant chemotherapy or radiotherapy. Similar operative mortality rates were observed: 7.5% for EPP and 5.4% for P/D. Patients who underwent P/D had a 9-month median survival and an 8.9% 2-year survival. Intrapleural chemotherapy offers the advantage of producing local levels of drug three to five times greater than serum levels, thereby improving antitumor efficacy with less systemic toxicity. Rusch et al [16,17] reported marginal improvement in outcome in patients who underwent P/D and postoperative intrapleural chemotherapy. Lee et al [18] treated 15 patients with P/D and intrapleural cisplatin and cytosine arabinoside. Median survival time from date of treatment was 11.5 months with a 100% local failure rate. Sauter et al [19] performed subtotal pleurectomy, intrapleural chemotherapy, and postoperative systemic chemotherapy. They observed significant toxicity and no effect on survival. The

use of intrapleural chemotherapy in conjunction with P/D is often compromised because of limitations in drug permeability through more than 1 mm of tumor [20,21]. A more extensive cytoreductive procedure may enhance the effectiveness of intrapleural chemotherapy. The coupling of hyperthermia and chemotherapy in multimodality treatment regimens holds promise because hyperthermia has been shown to increase tumor growth delay by enhancing antineoplastic drug uptake and cytotoxicity. Ratto et al [22] demonstrated that when combined with a surgical cytoreductive procedure, this combination could be pharmacokinetically advantageous with adequate safety profiles. Novel approaches to the treatment of MPM, including phototherapy, have gained increasing attention in recent years. Photodynamic therapy is a superficial treatment, and as a result, it does not mandate removal of the lung. Photodynamic therapy can be used to treat the lung surface after P/D, permitting lung preservation in patients with compromised pulmonary function while extending the effectiveness of P/D. The first clinical trial of intrapleural photodynamic therapy was reported by Pass et al [23] in 1990. Since then, multiple studies have demonstrated the safety and efficacy of surgery and intracavitary photodynamic therapy [24 – 28]. Additional therapies on the horizon include immune modulating interventions, intracavitary cytokine administration, and gene therapy.

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Summary P/D in combination with other therapies remains an effective weapon in the thoracic surgeon’s armamentarium for treating patients with MPM, particularly patients with limited lung function. A clear benefit has been demonstrated in terms of symptom relief. Further strategies aimed at eliminating residual disease in an effort to prevent locoregional recurrence and as potential curative therapies currently are being investigated.

References [1] Martini N, Bains M, Beattie Jr E. Indications for pleurectomy in malignant effusion. Cancer 1975;35: 734 – 8. [2] Jensik R, Cagle Jr J, Milloy F, Perlia C, Taylor S, Kofman S, et al. Pleurectomy in the treatment of pleural effusion due to metastatic malignancy. J Thorac Cardiovasc Surg 1963;46:322 – 30. [3] Antman K. Current concepts: malignant mesothelioma. N Engl J Med 1980;303:200 – 2. [4] Antman K. Clinical presentation and natural history of benign and malignant mesothelioma. Semin Oncol 1981;8:313 – 20. [5] McCormack P, Nagasaki F, Hilaris B, Martini N. Surgical treatment of pleural mesothelioma. J Thorac Cardiovasc Surg 1982;84:834 – 42. [6] Brancatisano R, Joseph M, McCaughan B. Pleurectomy for mesothelioma. Med J Aust 1991;154: 455 – 7. [7] Soysal O, Karaoglanoglu N, Demiracan S, Topcu S, Tastepe I, Kaya S, et al. Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery. Eur J Cardiothorac Surg 1997;11:210 – 3. [8] Martini N, McCormack P, Bains M, Kaiser L, Burt M, Hilaris B. Pleural mesothelioma. Ann Thorac Surg 1987; 43:113 – 20. [9] Sugarbaker D, Flores R, Jaklitsch M, Richards W, Strauss G, Corson J, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg 1999;117:54 – 63; discussion 63 – 5. [10] Allen K, Faber L, Warren W. Malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy. Chest Surg Clin N Am 1994;4:113 – 26. [11] Grondin S, Sugarbaker D. Pleuropneumonectomy in the treatment of malignant pleural mesothelioma. Chest 1999;116:450S – 4S. [12] Rusch V, Venkatraman E. The importance of surgical staging in the treatment of malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1996;111: 815 – 825; discussion 825 – 6.

[13] Hilaris B, Nori D, Kwong E, Kutcher G, Martini N. Pleurectomy and intraoperative brachytherapy and postoperative radiation in the treatment of malignant pleural mesothelioma. Int J Radiat Oncol Biol Phys 1984;10:325 – 31. [14] Maasilta P. Deterioration in lung function following hemithorax irradiation for pleural mesothelioma. Int J Radiat Oncol Biol Phys 1991;20:433 – 8. [15] Kutcher G, Kestler C, Greenblatt D, Brenner H, Hilaris B, Nori D. Technique for external beam treatment for mesothelioma. Int J Radiat Oncol Biol Phys 1987;13: 1747 – 52. [16] Rusch V, Saltz L, Venkatraman E, Ginsberg R, McCormack P, Burt M, et al. A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma. J Clin Oncol 1994;12:1156 – 63. [17] Rusch V. Pleurectomy/decortication in the setting of multimodality treatment for diffuse malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg 1997;9: 367 – 72. [18] Lee J, Perez S, Wang H, Figlin R, Holmes E. Intrapleural chemotherapy for patients with incompletely resected malignant mesothelioma: the UCLA experience. J Surg Oncol 1995;60:262 – 7. [19] Sauter E, Langer C, Coia L, Goldberg M, Keller S. Optimal management of malignant mesothelioma after subtotal pleurectomy: revisiting the role of intrapleural chemotherapy and postoperative radiation. J Surg Oncol 1995;60:100 – 5. [20] Los G, Verdegaal E, Mutsaers P, McVie J. Penetration of carboplatin and cisplatin into rat peritoneal tumor nodules after intraperitoneal chemotherapy. Cancer Chemother Pharmacol 1991;28:159 – 65. [21] Jacquet P, Stephens AD, Averbach AM, Ettinghausen SE, Dalton RR, Steves MA, et al. Analysis of morbidity and mortality in 60 patients with peritoneal carcinomatosis treated by cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy. Cancer 1996;77:2622 – 9. [22] Ratto G, Civalleri D, Esposito M, Spessa E, Alloisio A, De Cian F, et al. Pleural space perfusion with cisplatin in the multimodality treatment of malignant mesothelioma: a feasibility and pharmacokinetic study. J Thorac Cardiovasc Surg 1999;117:759 – 65. [23] Pass H, Tochner Z, DeLaney T, Smith P, Friauf W, Glatstein E, et al. Intraoperative photodynamic therapy for malignant mesothelioma. Annals of Thoracic Surgery 1990;50:687 – 8. [24] Takita H, Mang T, Loewen G, Antkowiak J, Raghavan D, Grajek J, et al. Operation and intracavitary photodynamic therapy for malignant pleural mesothelioma: a phase II study. Ann Thorac Surg 1994;58: 995 – 8. [25] Takita H, Dougherty T. Intracavitary photodynamic therapy for malignant pleural mesothelioma. Semin Surg Oncol 1995;11:368 – 71. [26] Friedberg J, Mick R, Stevenson J, Metz J, Zhu T, Buyske J, et al. A phase I study of Foscan-mediated

S.W. Cowan, T.T. Pechet / Thorac Surg Clin 14 (2004) 517 – 521 photodynamic therapy and surgery in patients with mesothelioma. Ann Thorac Surg 2003;75:952 – 9. [27] Pass H, Temeck B, Kranda K, Thomas G, Russo A, Smith P, et al. Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma. Ann Surg Oncol 1997;4: 628 – 33. [28] Baas P, Murrer L, Zoetmulder F, Stewart F, Ris H, van Zandwijk N, et al. Photodynamic therapy as adjuvant therapy in surgically treated pleural malignancies. Br J Cancer 1997;76:819 – 26. [29] Law M, Gregor A, Hodson M, Bloom H, TurnerWarwick M. Malignant mesothelioma of the pleura: a study of 52 treated and 64 untreated patients. Thorax 1984;39:255 – 9.

521

[30] Chahinian A, Pajak T, Holland J, Norton L, Ambinder R, Mandel EM. Diffuse malignant mesothelioma: prospective evaluation of 69 patients. Ann Intern Med 1982;6:746 – 55. [31] Ruffie P, Feld R, Minkin S, Cormier Y, Boutan-Laroze A, Ginsberg R, et al. Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 332 patients. J Clin Oncol 1989;7:1157 – 68. [32] Faber L. Surgical treatment of asbestos-related disease of the chest. Surg Clin North Am 1988;68(3):525 – 43. [33] Alberts A, Falkson G, Goedhals L, Vorobiof D, Van der Merwe C. Malignant pleural mesothelioma: a disease unaffected by current therapeutic maneuvers. J Clin Oncol 1988;6:527 – 35.