Surgical treatment of malignant pleural mesothelioma. Experience in the interdisciplinary approach in Slovenia

Background. The aim of the study was to identify perioperative morbidity and mortality, the category and mode of adjuvant treatment, local recurrence and survival in patients treated by extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM). Methods. From 2000 to 2003, 18 patients with MPM were referred to the Department of Thoracic Surgery in Ljubljana, and 17 of them were operated on. Two patients underwent explorative thoracotomy, and 15 patients were evaluated. Five female and nine male patients (aged 52-68 years) were treated by EPP and one male patient by pleurectomy. Eight patients received both adjuvant chemotherapy (ChT) and radiotherapy (RT), with cisplatin 100 mg/m2 + mitomycin C 6-10 mg/m2 or gemcitabine 1000 mg/m2 and external beam radiation with 24 Gy - 58 Gy respectively, three patients received no adjuvant therapy, three patients were treated by adjuvant ChT, two of them were given cisplatin 100 mg/m2 + mitomycin C 6-10 mg/m2, and one patient cisplatin 100 mg/m2 on the first day and gemcitabine 250 mg/m2 in prolonged 6 hours infusion on the first and on the eighth day. One patient was treated only by adjuvant RT. Results. There were no perioperative deaths and the postoperative morbidity was 42%. Of the 15 evaluable patients, and in the median follow up of 40 months (28-64), we noticed nine (60.0%) recurrences, seven local and two abdominal. Eight (53.3%) patients died, all because of the local progress of disease. Of the 3/15 patients without adjuvant treatment, one patient (T1bN0M0) is well 46 months after the operation, one patient (T2N0M0) got recurrence in abdomen, was treated with ChT and reoperation, and is still alive 31 month after the first surgical treatment. One patient (T2N0M0) died two months after the surgery due to local recurrence. In ChT+RT group, 6/8 patients died: the patient at stage T1aN0M0 died after nine months, the patient at stage T1bN0M0 died after nine months, two patients at the stage T2N0M0 died after four and 23 months respectively, the patient at stage T3N0M0 after 11 months, and the patients at stage T3N2M0 died seven months after the operation. Two out of eight patients are alive: the patient at stage T1bN0M0 is alive 43 months, and the patient at stage T2N0M0 is alive 28 months after the operation. In the ChT group, 1/3 patient (T2N0M0) died 6 months after the operation, 2/3 patients (T2N0M0 and T3N0M0) are well after 43 and 20 months respectively. The patient treated with adjuvant RT only is well 50 months after the surgical treatment. The median survival time was 20 months for the whole group of patients operated on, the 1-year survival rate was 53.3% and 2-year survival rate was 46.7%. Conclusions. In selected patients with MPM, complete surgical resection is indicated, followed by chemotherapy and radiotherapy. The operation could be performed safely with acceptable mortality and morbidity. Our group of patients is too small, the adjuvant therapies were too different to favour any of the treatment mode applied. Further randomised studies and standardised protocols are needed to evaluate the best mode of treatment for each patient.