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J Thorac Cardiovasc Surg 1999;117:54-65
© 1999 Mosby, Inc.
GENERAL THORACIC SURGERY |
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 nodenegative resection had extended survival.
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