Original article
General thoracic
Trimodality Therapy for Malignant Pleural Mesothelioma

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
https://doi.org/10.1016/j.athoracsur.2009.05.036Get rights and content

Background

Malignant pleural mesothelioma is a fatal disease. The optimal modality and sequence of therapy are controversial. We analyzed the outcomes of a cohort of mesothelioma patients treated with induction chemotherapy, followed by extrapleural pneumonectomy (EPP) and adjuvant radiation.

Methods

The study comprised a retrospective cohort of 46 patients treated with induction chemotherapy, followed by EPP, during a 10-year period. Of these, 24 completed adjuvant external beam radiotherapy (EBRT), and 14 had intensity-modulated radiotherapy (IMRT).

Results

Mean follow-up was 20.6 months (range, 0.5 to 75 months). Operative mortality after EPP was 4.3% (n = 2). Pathologic stage was p0, 4.3%; pII, 23.9%; pIII, 56.5%; and pIV, 15.2%. Median overall survival was 24 months. On univariate analysis and Cox proportional hazards model, only nodal metastases (hazard ratio, 3.7; 95% confidence interval, 1.6 to 8.7; p = 0.002) was a significant predictor of survival. First site of recurrence was local in 12, the contralateral chest in 5, abdominal in 8, and distant in 5. The incidence of local recurrence was 14.3% with IMRT vs 41.7% with EBRT (p = 0.03). The time to local recurrence with the use of IMRT was 12 months vs 7 for EBRT (p = 0.19).

Conclusions

Induction chemotherapy, followed by EPP and adjuvant radiotherapy for selected patients with mesothelioma, is safe, with acceptable operative mortality. Adjuvant IMRT may be more effective in terms of local control than EBRT.

Section snippets

Material and Methods

This study was fully approved by the Swedish Medical Center Institutional Research Board.

Results

We evaluated 55 patients after they completed induction chemotherapy. The distribution of regimens is summarized in Table 1. The combination of cisplatin, methotrexate, and vinblastine was the preferred chemotherapy regimen early on in this experience. The last 19 patients received pemetrexed in combination with cisplatin or carboplatin.

Of the 55 patients who underwent mediastinoscopy, 2 had positive nodes and were deemed inoperable. Of 53 patients who underwent exploration for resection, 7

Comment

The treatment of early stage MPM remains very challenging. Sugarbaker and colleagues [2] have produced the largest experience of trimodality treatment of MPM with EPP, followed by adjuvant chemotherapy and sequential radiotherapy. Other centers have used induction chemotherapy, followed by resection and adjuvant radiotherapy [3, 4, 5, 6], and the present study adds further weight that a trimodality regimen of induction chemotherapy, surgical resection, and radiotherapy is a feasible means of

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