Malignant Pleural Mesothelioma: Surgical Management in 285 Patients

Background: Malignant pleural mesothelioma is a rare, aggressive, and deadly malignancy. Despite increasing incidence, no treatment modality is accepted standard of care. This report analyzes our experience with surgical management of mesothelioma.

Methods: All patients with surgery for mesothelioma from January 1985 through December 2003 were retrospectively reviewed.

Results: There were 285 patients with a median age of 66 years (range, 26 to 91 years). One hundred forty-six patients (51%) had biopsy only, 73 (26%) had extrapleural pneumonectomy, 34 (12%) had subtotal parietal pleurectomy, 22 (8%) underwent exploration without resection, and 10 (3%) had total pleurectomy. Histopathology was epithelial, nonepithelial, and unclassified in 134, 108, and 43 patients, respectively. Twenty patients were stage IA, 82 patients were stage IB, 24 patients were stage II, 75 patients were stage III, 60 patients were stage IV, and 24 patients were of unknown stage. Fifty-three patients (19%) had chemotherapy alone, 16 (5.6%) had radiation alone, and 42 (14.7%) had both. Thirty-day operative mortality was 6.3% and was not significantly associated with the operative procedure (p = 0.79). Fifty-one percent of extrapleural pneumonectomy patients had major complications, significantly greater than patients having any other procedure (p < 0.001). Median follow-up was 11 months (range, 0 to 7 years). Overall median survival was 10.7 months; however, for patients having extrapleural pneumonectomy, median survival was 16 months. One-, 2-, and 3-year survival after extrapleural pneumonectomy was 61%, 25%, and 14%, respectively.

Conclusions: Extrapleural pneumonectomy can be performed with similar 30-day mortality as other procedures for malignant pleural mesothelioma with a median survival better than subtotal pleurectomy, exploration without resection, and biopsy alone. However, extrapleural pneumonectomy has significant morbidity and a 3-year survival of only 14%.