Extrapleural Pneumonectomy in the Treatment of Epithelioid Malignant Pleural Mesothelioma

Novel Prognostic Implications of Combined N1 and N2 Nodal Involvement Based on Experience in 529 Patients

Abstract

Objective: 

We review our 24-year experience with extrapleural pneumonectomy (EPP) in the treatment of epithelioid malignant pleural mesothelioma (MPM).

Background: 

Recent publications, particularly the MARS (Mesothelioma and Radical Surgery) feasibility study by Treasure et al, have questioned the safety and efficacy of EPP for MPM.

Methods: 

An institutional review board–approved, prospective, single-center database was retrospectively reviewed. Descriptive statistics and Kaplan-Meier analysis of overall survival are reported.

Results: 

From 1988 to 2011, a total of 529 patients with epithelioid MPM underwent complete resection by EPP as part of a multimodality strategy. Among these, 131 (25%) were women, and the median age was 59 (range, 17–79) years. Median postoperative hospital stay was 10 (range, 1–101) days. Twenty-six patients (5%) experienced 30-day or in-hospital mortality. Median overall survival was 18 months, with 1-, 3-, 5-, and 10-year survival rates of 67%, 28%, 14%, and 4%, respectively. Outcome by pathologic lymph node status (N, median overall survival) was N0: 224, 26 months; N1: 118, 17 months; N2: 181, 13 months; N3: 5, 7 months; Nx: 1, not evaluable.

Conclusions: 

EPP has evolved as an effective method for macroscopic complete resection. This study confirms that lymph node status is significantly correlated with overall survival in patients with epithelioid MPM undergoing EPP and suggests that those with simultaneous involvement of N1 and N2 stations are at increased risk. This observation underscores the need for thorough staging of both N1 and N2 stations and has implications for revision of MPM staging criteria.

In Brief

Extrapleural pneumonectomy for malignant pleural mesothelioma is a complex surgical procedure used in selected patients with localized disease as part of a multimodality strategy. At high-volume centers, this operation is associated with extended survival, particularly for patients with epithelioid tumor histology and uninvolved extrapleural lymph nodes. Simultaneous N1–N2 involvement carries a worse prognosis than N1 or N2 involvement alone.