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The following is an abstract of an
article authored by Dr. David Sugarbaker of the Brigham and Womens Hospital in Boston. Dr.
Sugarbaker was kind enough to furnish us with a copy of the abstract in anticipation of
his speech at the 78th Annual Meeting of the American Association for Thoracic Surgery,
which will take place on May 3-6, 1998 in Boston, Massachusetts. Note that the patients
with epithelial tumors have a significantly longer mean survival than the patients with
mixed type/sarcomatous tumor. --Roger Worthington
Resection Margins, N2 status and Cell type
Determine Survival in Trimodality Therapy of Malignant Pleural Mesothelioma (MPM): Results
in 183 Patients
Objectives: We review our
experience with extrapleural pneumonectomy (EPP) in the multimodality management of MPM.
Methods: From 1980 to 1997, 183
consecutive patients underwent trimodality therapy involving EPP followed by adjuvant
chemotherapy and radiotherapy. Standardized systematic pathologic analysis was undertaken.
Results: The cohort included 43
women and 140 men with a mean age of 57 years (range 31-76) and a median followup interval
of 13 months. Overall survival was 36% at 2 yrs and 14% at 5 yrs (median 17 mo). There
were seven perioperative deaths (3.8% mortality). Factors affecting long-term survival
were evaluated in 176 patients surviving surgery (among these, survival was 38% at 2 yrs
and 15% at 5 yrs; median 19 mo). As indicated in the table below, lack of N2 nodal
involvement, negative resection margins and epithelial histology were associated with
improved survival. Factorial grouping by N2 status and resection margins significantly
stratified survival among all patients surviving surgery (p<0.02), and among those with
epithelial histology (p<.02). Thirty-one patients with epithelial tumors, negative
resection margins and without N2 involvement had a 51 mo median survival (68% 2-yr, 46%
5-yr). A clinico-pathologic staging system previously published stratified survival
(p<0.05; see table).
|
Variable
|
N
|
2-Year
|
5-Year
|
Median (months)
|
P Value
|
|
Epithelial
Mixed/Sarcom
|
103
73
|
52%
16%
|
21%
0%
|
26
13
|
0.0001
|
|
Margins(+)
Margins(-)
|
110
66
|
33%
44%
|
9%
25%
|
15
23
|
0.02
|
|
N2(+)
N2(-)
|
40
136
|
23%
42%
|
0%
17%
|
14
21
|
0.004
|
|
Epithel. N2(+)
Epithel. N2(-)
|
21
82
|
38%
56%
|
0%
24%
|
20
34
|
0.052
|
|
Epithel N2(+) Marg(+)
Epithel N2(+) Marg(-)
Epithel N2(-) Marg(+)
Epithel N2(-) Marg(-)
|
12
9
51
31
|
29%
43%
49%
68%
|
0%
0%
14%
46%
|
14
22
22
51
|
0.013
|
|
Stage I
Stage II
Stage III |
66
41
69
|
53%
44%
17%
|
20%
14%
14%
|
25
20
16
|
0.048
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These data support the following conclusions:
-
Multimodality therapy including EPP is
feasible in selected patients with MPM,
- Microscopic resection margins affect long-term survival,
pointing to the need for further investigation of local-regional control strategies,
- Mediastinoscopy to evaluate N2 nodes is recommended, and
- Patients with epithelial, margin-negative, N2-negative
resection enjoy long-term survival.
*** POSTED APRIL 14, 1998 ***
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