Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma.

ABSTRACT

OBJECTIVES: There is a body of opinion that advocates extrapleural pneumonectomy (EPP) as the only radical treatment option for locally advanced (T3/T4) malignant pleural mesothelioma (MPM). We tested the hypothesis that lung-sparing total pleurectomy (LSTP) can be as effective as EPP in locally advanced MPM with reduced risk. METHODS: We analysed prospective data on 165 patients (128 with epithelioid and 37 with biphasic MPM) with pT3 (n = 108) and pT4 (n = 57) tumours. Ninety-eight (59.4%) of the patients underwent EPP and 67 (40.6%) LSTP. We compared intergroup differences in length of stay (LOS), post-operative complications, survival, pattern of disease progression and disease-free interval (DFI). RESULTS: There were significantly more complications after EPP 67 (68%) vs. 29 (43%) in LSTP, P = 0.002. Thirty-day mortality was 7% for EPP and 3% for LSTP (P = 0.31). LOS was similar (mean 19 days for EPP, 15 days for LSTP, P = 0.19). We noted only minor differences in the initial site of disease progression. In 33 (41%) of EPP patients, disease progressed locally compared with 22 (44%) after LSTP. Seventeen patients post-EPP (21%) had distal progression compared with only three (6%) post-LSTP and synchronous distal and local recurrence was similar 15 (19%) post-EPP vs. 12% for LSTP (P = 0.11). There was no significant intergroup difference in median survival EPP 14.7 months (SE 1.3, 95% CI 12.2-17.2) vs. LSTP 13.4 months (SE 1.9, 95% CI 9.7-17.1), P = 0.91, nor in DFI EPP 10.7 months (SE 0.8, 95% CI 9-12) vs. LSTP 16 months (SE 1, 95% CI 9-22). In chemonaive patients (n = 124), adjuvant chemotherapy was received by significantly more patients after LSTP (32/53 LSTP vs. 26/71 EPP patients, P = 0.011). Estimated 1-5 years survival for EPP was 58, 30, 11, 9 and 6% and for LSTP 52, 28, 20, 13 and 4%. CONCLUSIONS: In disagreement with standard opinion, we advocate LSTP as the procedure of choice in locally advanced MPM it offers at least equally as good oncological results as EPP in this group of patients with reduced early complications. Despite a tendency for increased local recurrence in the LSTP group, overall survival is not compromised.