Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years

Abstract

Background: The purpose of this study was to assess survival for patients with malignant pleural mesothelioma (MPM), epithelial subtype, utilizing extended pleurectomy-decortication combined with intraoperative photodynamic therapy (PDT) and adjuvant pemetrexed-based chemotherapy.

Methods: From 2005 to 2013, 90 patients underwent lung-sparing surgery and PDT for MPM. All patients had a preoperative diagnosis of epithelial subtype, of which 17 proved to be of mixed histology. The remaining 73 patients with pure epithelial subtype were analyzed. All patients received lung-sparing surgery and PDT; 92% also received chemotherapy. The median follow-up was 5.3 years for living patients.

Results: Macroscopic complete resection was achieved in all 73 patients. Thirty-day mortality was 3% and 90-day mortality was 4%. For all 73 patients (89% American Joint Commission on Cancer stage III/IV, 69% N2 disease, median tumor volume 550 mL), the median overall and disease-free survivals were 3 years and 1.2 years, respectively. For the 19 patients without lymph node metastases (74% stage III/IV, median tumor volume 325 mL), the median overall and disease-free survivals were 7.3 years and 2.3 years, respectively.

Conclusions: This is a mature dataset for MPM that demonstrates the ability to safely execute a complex treatment plan that included a surgical technique that consistently permitted achieving a macroscopic complete resection while preserving the lung. The role for lung-sparing surgery is unclear but this series demonstrates that it is an option, even for advanced cases. The overall survival of 7.3 years for the node negative subset of patients, still of advanced stage, is encouraging. Of particular interest is the overall survival being approximately triple the disease-free survival, perhaps PDT related. The impact of PDT is unclear, but it is hoped that it will be established by an ongoing randomized trial.

Figure 1. Survival Analysis of entire 73 patient cohort

Figure 2. Effect of Lymph Node Metastases on Survival and Progression Free Survival

Analysis the effect of lymph node metastases was performed, with patients grouped as either node negative (N0) or node positive (N1 or N2). Overall survival for patients with or without lymph node metastases was 7.3 years ± 0.16 years vs 1.9 years ± 0.5 years, respectively. Progression free survival for patients with or without lymph node metastases was 2.2 years ± 1.1 years vs 0.8 years ± 0.1 years, respectively.

Figure 3. Effect of First Treatment Failure Site on Survival and Progression Free Survival

Analysis of patterns of initial treatment failure was performed, with patients grouped as either experiencing an initial recurrence involving 1) locoregional site(s) vs 2) distant ± locoregional site(s). Overall survival for patients experiencing initial treatment failure at only locoregional vs distant ± locoregional site(s) was 2.7 years ± 0.9 years vs 1.9 years ± 0.9 years, respectively. Progression free survival for patients experiencing only locoregional vs distant ± locoregional recurrence(s) was 1.0 years ± 0.3 years vs 1.0 years ± 0.2 years, respectively.