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Surgical Treatment in the Management of Malignant Pleural Mesothelioma: A Single Institution’s Experience

¹ Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
² Department of Thoracic Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
³ Department of Radiotherapy, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

Correspondence: Address correspondence and reprint requests to: J. W. van Sandick, MD, PhD; E-mail: j.v.sandick{at}nki.nl

Background: A minority of patients with malignant pleural mesothelioma (MPM) are considered for surgery. To achieve a microscopically radical resection, combination with other treatment modalities is mandatory. The most effective combination is unknown. In our institute we have retrospectively analyzed the results of two combined modality regimens containing surgery.

Patients: Between January 2002 and September 2005, 15 MPM patients were treated with extrapleural pneumonectomy (EPP) and postoperative hemithoracic radiation (RT; 54 Gy). Previously, between January 1999 and December 2001, 20 patients underwent a combination of cytoreductive surgery – pleurectomy or EPP – and intraoperative hyperthermic intrathoracic chemotherapy (HITHOC), followed by radiotherapy to the thoracotomy scar and drainage tracts (24 Gy).

Results: The median operating time for EPP/RT was shorter (5.3 versus 6.9 h; P < 0.0001). Postoperative complications occurred in 8 EPP/RT patients (53%) and in 14 HITHOC patients (70%). Two HITHOC patients died postoperatively. Median overall survival was 29 months for EPP/RT patients and 11 months for HITHOC patients (P = ns). The median time to local recurrence was not reached for EPP/RT patients, and was 9 months for HI-THOC patients (P = 0.003). Local control was achieved in ten EPP/RT patients (67%) with a follow-up of 5–59 months compared to four HITHOC patients (20%) with a follow-up of 4–27 months.

Conclusions: In highly selected patients local control can be achieved with combination therapy but is accompanied by a high rate of (surgical) complications. Distant failure rates warrant further studies exploring the role of systemic chemotherapy while the use of cytoreductive surgery with intraoperative chemoperfusion for MPM is not supported.

Key Words: Malignant pleural mesothelioma • Extrapleural pneumonectomy • Intraoperative hyperthermic intrathoracic chemotherapy • Adjuvant radiotherapy • Combined modality treatment