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Manjit S. Bains
Valerie W. Rusch
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J Thorac Cardiovasc Surg 2008;135:620-626
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: Results in 663 patients

Raja M. Flores, MDa,*, Harvey I. Pass, MDd, Venkatraman E. Seshan, PhDb, Joseph Dycoco, BAa, Maureen Zakowski, MDc, Michele Carbone, MDe, Manjit S. Bains, MDa, Valerie W. Rusch, MDa

a Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
b Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
c Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
d Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY
e Department of Pathology, University of Hawaii, Honolulu, Hawaii

Received for publication May 3, 2007; revisions received September 13, 2007; accepted for publication October 22, 2007.

* Address for reprints: Raja M. Flores, MD, Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-879, New York, NY 10021. (Email: floresr{at}mskcc.org).

Objective: The optimal procedure for resection of malignant pleural mesothelioma is controversial, partly because previous analyses include small numbers of patients. We performed a multi-institutional study to increase statistical power to detect significant differences in outcome between extrapleural pneumonectomy and pleurectomy/decortication.

Methods: Patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy or pleurectomy/decortication at 3 institutions were identified. Survival and prognostic factors were analyzed by the Kaplan–Meier method, log-rank test, and Cox proportional hazards analysis.

Results: From 1990 to 2006, 663 consecutive patients (538 men and 125 women) underwent resection. The median age was 63 years (range, 26–93 years). The operative mortality was 7% for extrapleural pneumonectomy (n = 27/385) and 4% for pleurectomy/decortication (n = 13/278). Significant survival differences were seen for American Joint Committee on Cancer stages 1 to 4 (P < .001), epithelioid versus non-epithelioid histology (P < .001), extrapleural pneumonectomy versus pleurectomy/decortication (P < .001), multimodality therapy versus surgery alone (P < .001), and gender (P < .001). Multivariate analysis demonstrated a hazard rate of 1.4 for extrapleural pneumonectomy (P < .001) controlling for stage, histology, gender, and multimodality therapy.

Conclusion: Patients who underwent pleurectomy/decortication had a better survival than those who underwent extrapleural pneumonectomy; however, the reasons are multifactorial and subject to selection bias. At present, the choice of resection should be tailored to the extent of disease, patient comorbidities, and type of multimodality therapy planned.

Abbreviations and Acronyms EPP = extrapleural pneumonectomy; MPM = malignant pleural mesothelioma; P/D = pleurectomy/decortication






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