Should we continue to offer extrapleural pneumonectomy to selected mesothelioma patients? A single center experience comparing surgical and non-surgical management.

Malignant pleural mesothelioma remains an incurable disease for which the optimal therapeutic approach remains an extremely debated issue. Though not yet clearly defined, a subset of patients may benefit from a surgery-based multimodal treatment plan, beyond what would be expected with non-surgical therapies only. Indeed, despite some disappointing results on the feasibility of a multimodality treatment (chemotherapy ± surgery and post-operative radiation therapy) based on a lung sacrificing surgery (extrapleural pleuropnemonectomy) have been recently reported, the question concerning the role of extrapleural pneumonectomy in selected mesothelioma patients is still unanswered. In the light of this, we have reviewed our mono-institutional retrospective experience in the mesothelioma management, discussing on the role of extrapleural pneumonectomy in the multimodality treatment.

Outcome and prognostic factors of pleural mesothelioma after surgical diagnosis and/or pleurodesis.

OBJECTIVE: The objective of this study was to evaluate long-term survival and prognostic factors in patients with malignant pleural mesothelioma. METHODS: All consecutive patients referred for surgical diagnosis and/or pleurodesis for malignant pleural mesothelioma between 2000 and 2010 were studied. The following parameters were prospectively recorded: age, sex, tobacco consumption, asbestos exposure, type and duration of symptoms, American Society of Anesthesiologists (ASA) score, body mass index, preoperative C-reactive protein levels, white blood cells and platelet count, pachypleuritis on chest radiograph, type of diagnostic surgical procedure, histologic type, modality of pleurodesis, and chemotherapy. Survival was assessed on March 1, 2011. RESULTS: A total of 170 patients were included. For the entire population, median survival was 12 months (95% confidence interval [CI], 10-15). Two-, 5-, and 7-year overall survival was 26% (95% CI, 19-35), 11% (95% CI, 6-21), and 5% (95% CI, 9-22), respectively. Asbestos exposure, age, ASA class III versus ASA classes I and II, nonepithelioid histology, C-reactive protein levels >3 mg/L, and white cell count >12,000/mm(3) influenced outcome in univariate analysis. Multivariate analysis showed that nonepithelioid histology (hazard ratio [HR], 2.76; 95% CI, 1.50-5.08); age (HR, 1.05; 95% CI, 1.01-1.08); C-reactive protein levels between 4 and 50 mg/L, and >51 (HR, 2.28; 95% CI, 1.18-4.42; and HR, 2.69; CI, 1.29-5.60, respectively); and leukocytosis >12,000/mm(3) (HR, 2.28; 95% CI, 1.22-4.25) were independent worse survival predictors. CONCLUSIONS: Median survival in an unselected population of patients with malignant pleural mesothelioma treated nonsurgically is 12 months. Nonepithelioid histology, older age, abnormal C-reactive protein levels, and leukocytosis are independent predictors of worse survival.

Optimization of small-cell lung cancer chemotherapy with heparin: a comprehensive retrospective study of 239 patients treated in a single specialized center.

PURPOSE: In first-line management for small-cell lung cancer (SCLC), the combination of a platinum salt and etoposide is recommended, with thoracic radiotherapy and prophylactic cranial irradiation in selected patients. Anticoagulants, including heparin, are rarely used. We analyzed the results of these different treatments in a comprehensive population of patients with SCLC. PATIENTS AND METHODS: We retrospectively analyzed clinical and therapeutic characteristics of SCLC patients managed in our center during the period 1990-2002. RESULTS: First-, second- and third-line chemotherapy was received by 98.3, 47.3 and 11.7%, respectively; 55% received curative heparin. The 2-year survival rates were 31 and 7% among patients with localized and metastatic disease, 33 and 15% among patients treated with the PCDE (cisplatin-cyclophosphamide-doxorubicin-etoposide) regimen with and without heparin, and 27 and 12% among patients treated with the PE (cisplatin or carboplatin-etoposide) regimen with and without heparin, respectively. The 2-year survival rate among the 27 patients who received an optimal combination of PCDE, heparin, thoracic radiotherapy and prophylactic cranial irradiation was 44.2%. In multivariate analysis, localized disease, younger age, use of heparin and inclusion in a clinical trial were independently associated with a better outcome. CONCLUSION: Despite the bias inherent in a retrospective, single-center study, these results support chemotherapy optimization for SCLC patients and confirm the value of heparin in this setting.

Primary chordoma of the lung.

We report the case of a 79-year-old woman referred to our institution for persistent cough and right-sided chest pain. A computed tomographic scan revealed a 2-cm round nodule in the right lower lobe. A wedge resection of the lesion was achieved by video-assisted thoracic surgery. Pathologic examination was consistent with the diagnosis of chordoma. Magnetic resonance imaging of the whole spine and skull basis was normal. Therefore, a diagnosis of primary lung chordoma, an exceptional condition, could be established.

Oral second- and third-line lomustine-etoposide-cyclophosphamide chemotherapy for small cell lung cancer.

PURPOSE: There is no standard therapy for progressive or recurrent small cell lung cancer (SCLC). Lomustine, etoposide and cyclophosphamide oral chemotherapy were evaluated in a feasibility study of efficacy survival and toxicity. PATIENTS AND METHODS: 71 patients were included in this study, 36 in second-line and 35 in third-line chemotherapy. They received lomustine (CCNU) 80 or 120mg on D1 only, etoposide 100mg from D1 until D6 up to D14 and cyclophosphamide 100mg from D1 until D6 up to D14 every 4 weeks. The dosages of CCNU and duration of administration of the other two drugs were adapted to an original therapeutic risk level table on D1 and throughout treatment. Evaluation based on clinical status, response and weekly blood counts was performed before each cycle until progression. RESULTS: 70 patients were evaluable. They received between 1 and 20 cycles of treatment (mean=3.7 for second-line and 3.0 for third-line treatment). Complete responses were observed for 3 patients in each line, and partial responses were noted in 13 patients in second-line and 8 patients in third-line, resulting in a total response rate of 27/70=38%. Median-survival time estimated from the start of second- or third-line treatment was the same in the two subgroups: 4.4 months, but the patients in two subgroups presented different clinical characteristics. Haematological toxicity was severe with three toxic deaths as frequently observed in this setting, but hospitalisations were uncommon during this fully oral treatment that provided a very good quality of life for these out-patients. Consumption of health care resources for this low-cost and ambulatory treatment was limited. CONCLUSION: The similar efficacy with acceptable safety, the ease of administration in out-patients and the economical advantages justify comparison of this oral chemotherapy with conventional intravenous chemotherapy. A randomised phase II trial is on-going in France for second-line SCLC patients on this theme.

[Medico economic analysis in first line chemotherapy in advanced lung cancer]. / Analyse economique de deux chimiothérapies en première ligne du cancer pulmonaire a un stade avancé.

Our objective was to analyse economic consequences modifying first line chemotherapy in treatment non small cell lung cancer IIIB-IV. Therefore a cost minimisation has been performed. Resources consumption were collected in a Pneumology department for 21 patients receiving previously mitomycine-ifosfamide-platin and for the 21 first patients receiving vinorelbine-platin, new patients diagnosed during year 2001. Costs were derived from hospital accounting system, economic analysis performed from the hospital and from the health French system points of view. Activity Synthetic Index point decrease of 2.9% per patient in vinorelbine-platin versus mitomycine-ifosfamide-platin, as an increase of 64.6% of hospital drug spending is registered (1,893 Euro versus 1,150 Euro) and an over cost of 15.7% for health French system (14179 Euro versus 12,257 Euro). Whatever the perspective of economic analysis, vinorelbine-platin arm is dominated by the mitomycine-ifosfamide-platin arm.

Routine once-weekly darbepoetin alfa administration is cost-effective in lung cancer patients with chemotherapy-induced anemia: a Markov analysis.

BACKGROUND: Despite the clinical efficacy of recombinant human erythropoietin (RHE) on chemotherapy-induced anemia, most cost-effectiveness studies have given unfavorable results. OBJECTIVE: To determine the cost of managing anemia in unselected patients receiving chemotherapy for lung cancer, and the efficacy and cost-effectiveness of RHE. METHOD: We constructed Markov models of two cohorts of patients who received (n=94) or did not receive (n=89) darbepoetin (one weekly injection when the hemoglobin level fell below 11 g/dl), focusing on changes in hemoglobin levels, transfusion requirements, anemia management costs, and the cost-effectiveness ratios of the two management strategies. RESULTS: The use of RHE significantly reduced the proportion of patients needing transfusions (from 33.6% to 19.1%, p<0.05) and the number of red cell units used by transfusion (from 2.97+/-1.47 to 2.11+/-0.47, p<0.01). Markov modeling showed that the RHE strategy significantly increased the mean Hb level (13+/-0.5 g/dl versus 11.9+/-1g/dl, p<0.001), at the price of an increase in the main cost (respectively, US$ 1732+/-897 and 996+/-643; p<0.01). The cost-effectiveness ratio favored the RHE strategy (7.02 versus 9.04). Sensitivity analysis showed that the RHE strategy remained dominant in most situations. CONCLUSION: Routine use of RHE appears to be cost-effective in patients receiving chemotherapy for lung cancer.