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EXTRAPLEURAL PNEUMONECTOMY OR VATS PLEURECTOMY / DECORTICATION FOR EARLY STAGE MALIGNANT MESOTHELIOMA? A CASE CONTROL STUDY

Glenfield Hospital, Leicester, United Kingdom

PURPOSE: To examine whether radical surgery has benefits over debulking for malignant pleural mesothelioma (MM), we compared the results of extrapleural pneumonectomy (EPP) and VATS pleurectomy / decortication (P/D) in a case control study.

METHODS: We analysed the results of EPP or P/D in 145 consecutive patients with early stage MM over a seven year period. If deemed medically fit, patients received EPP. Those unfit underwent P/D (a subtotal parietal pleurectomy followed by visceral decortication to gain full lung expansion). The distribution of known prognostic factors between the groups was compared. Postoperative survival and time to progression (TTP) data were analysed.

RESULTS: EPP was performed in 95 and P/D in 50 patients. Those in the P/D group were older (median age 68 vs. 57 years, p<0.001), of poorer performance status (p=0.001) and were associated with poorer EORTC (p=0.002) and CALGB prognostic groups(p=0.03). Pathological TNM stages in the EPP group were : 6 stage I, 8 stage II, 56 stage III and 25 stage IV. The P/D group had shorter hospital stay (median 6 vs. 13 days, p=0.001). In-hospital mortality was 7 (7.4%) and 3 (6%) in the EPP and P/D groups respectively. There was no difference in survival between the EPP and P/D groups (p=0.48). Compared to the P/D group, median survival was longer in the epithelioid node negative cases (29.8 months, p=0.03) but not in those with positive N2 nodes (p=0.5). P/D was associated with a shorter TTP (7.6 vs 12.0 months, p=0.01). There was no planned adjuvant chemotherapy or hemithorax irradiation in the P/D. In the EPP group, 20 received neoadjuvant and 17 adjuvant treatment.

CONCLUSION: Radical surgery (EPP) for mesothelioma may achieve better local control than debulking surgery but this has not been shown to influence distant disease progression or survival. However, survival following VATS P/D appears to be no better than for the N2 positive EPP group.

CLINICAL IMPLICATIONS: We conclude that the role of EPP should be subject to evaluation in a randomised trial.

DISCLOSURE: Antonio Martin-Ucar, None.