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J Thorac Cardiovasc Surg 1999;117:54-65
© 1999 Mosby, Inc.

GENERAL THORACIC SURGERY

RESECTION MARGINS, EXTRAPLEURAL NODAL STATUS, AND CELL TYPE DETERMINE POSTOPERATIVE LONG-TERM SURVIVAL IN TRIMODALITY THERAPY OF MALIGNANT PLEURAL MESOTHELIOMA: RESULTS IN 183 PATIENTS

David J. Sugarbaker, MD, Raja M. Flores, MD, Michael T. Jaklitsch, MD, William G. Richards, PhD, Gary M. Strauss, MD, Joseph M. Corson, MD, Malcolm M. DeCamp, Jr, MD, Scott J. Swanson, MD, Raphael Bueno, MD, Jeanne M. Lukanich, MD, Elizabeth Healey Baldini, MD, MPH, Steven J. Mentzer, MD

From the Division of Thoracic Surgery and the Department of Pathology, Brigham and Women's Hospital; Surgical Services and the Department of Adult Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Mass; and Hematology-Oncology, University of Massachusetts, Worcester, Mass.

Read at the Seventy-eighth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 3-6, 1998.

Received for publication May 8, 1998. Revisions requested June 30, 1998. Revisions received Sept 25, 1998. Accepted for publication Sept 29, 1998. Address for reprints: David J. Sugarbaker, MD, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA 02115.

Objectives: Our aim was to identify prognostic variables for long-term postoperative survival in trimodality management of malignant pleural mesothelioma.
Methods: From 1980 to 1997, 183 patients underwent extrapleural pneumonectomy followed by adjuvant chemotherapy and radiotherapy.
Results: Forty-three women and 140 men (age range 31-76 years) had a median follow-up of 13 months. The perioperative mortality rate was 3.8% (7 deaths) and the morbidity, 50%. Survival in the 176 remaining patients was 38% at 2 years and 15% at 5 years (median 19 months). Univariate analysis identified 3 prognostic variables associated with improved survival: epithelial cell type (52% 2-year survival, 21% 5-year survival, 26-month median survival; P = .0001), negative resection margins (44% at 2 years, 25% at 5 years, median 23 months; P = .02), and extrapleural nodes without metastases (42% at 2 years, 17% at 5 years, median 21 months; P = .004). Using the Cox proportional hazards, the relative risk of death was calculated for nonepithelial cell type (OR 3.0, CI 2.0-4.5; P < .0001), positive resection margins (OR 1.7, CI 1.2-2.6; P = .0082), and metastatic extrapleural nodes (OR 2.0, CI 1.3-3.2; P = .0026). Thirty-one patients with 3 positive variables had the best survival (68% 2-year survival, 46% 5-year survival, median 51 months; P = .013). A previously published staging system using these variables stratified survival (P < .05).
Conclusions: (1) Multimodality therapy including extrapleural pneumonectomy is feasible in selected patients with malignant pleural mesotheliomas, (2) pre-resectional evaluation of extrapleural nodes may select patients for radical therapy, (3) microscopic resection margins affect long-term survival, highlighting the need for further investigation of locoregional control, and (4) patients with epithelial, margin-negative, extrapleural node–negative resection had extended survival.




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