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Cytoreductive Surgery Combined with Post-operative Chemotherapy and Radiotherapy Offers Better Survival Benefit Than Pleuro-pneumonectomy in Diffuse Malignant Pleural Mesothelioma: A 25-year Experience
H. Luckraz, M. Rahman, N. Patel, A. Szafranek, A. R. Gibbs, E. G. Butchart. University Hospital of Wales, Cardiff, United Kingdom,
BACKGROUND:
Optimal management of diffuse malignant pleural mesothelioma (DMPM) remains unclear. We report our 25-year surgical experience with DMPM with emphasis on surgical procedure and post-operative adjuvant therapy
METHODS:
Consecutive patients referred for surgical management of DMPM who survived longer than 30 days post operatively were included in this study (n=123). Surgical options were pleuro-pneumonectomy (PPM) for Butchart stage I disease in clinically fit patients (n=42). Pleurectomy / decortication was performed in patients who were either not fit for PPM or had advanced disease (Butchart stage II & III) or both. Post-operative adjuvant therapy included either chemotherapy, radiotherapy or both
RESULTS:
Mean (SD) patient age was 58.3 (9.9) years, 87% males. The longest survival (median 20.4 months, IQR: 6.4 to 28.1 months) occurred in the pleurectomy / decortication group who received both post-operative chemotherapy and radiotherapy (n=22) (log rank= 0.02, Figure 1). On multivariate analyses of age, gender, Butchart stage, histological type, surgical procedure and adjuvant chemotherapy, radiotherapy and both, pleurectomy / decortication combined with chemotherapy and radiotherapy was the strongest predictor of prolonged survival (OR= 3.6, p=0.02). PPM whether or not combined with adjuvant therapy provided no significant survival advantage in comparison to pleurectomy / decortication (overall median survival 11.3 v/s 9.2 months, p=0.98)
CONCLUSIONS:
Cytoreductive surgery rather than PPM combined with post-operative adjuvant therapy provides better survival despite either advanced disease or surgically less fit patients. Thus, the optimal treatment of DMPM should be pleurectomy / decortication followed by chemotherapy and radiotherapy in all sugical patients. 
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