Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma. A treatment option in selected cases?

OBJECTIVE: There is no standard treatment for diffuse malignant pleural mesothelioma. Sporadic extrapleural pneumonectomy for the disease in off-protocol set has been performed when the disease was judged as being confined to a hemithorax. SUBJECT: To evaluate the role of extrapleural pneumonectomy in the treatment for the disease, cases that underwent surgery in a single institution are reported with descriptions of the stages based on the system from the International Mesothelioma Interest Group.
METHODS: Patients with diffuse malignant pleural mesothelioma treated with extrapleural pneumonectomy from 1989 to 1995 at the National Cancer Center Hospital East were reviewed.
RESULTS: Five patients underwent extrapleural pneumonectomy. All were male. Their ages ranged from 48 to 68 years. The disease was right-sided in two and left-sided in three. The histologic subtype was epithelial in three, and mixed epithelial and sarcomatous in the other two. Post-surgical pathologic stage was Ib (T1bN0M0) in three, III (T3N1M0) in one, and IV (T4N2M0) in one. There was no treatment-related death. Two cases with epithelial histology were alive with local recurrence on the chest wall at 75 months and at 51 months after surgery, respectively. A case with mixed epithelial and sarcomatous histology died of an esophageal cancer at 25 months after surgery. The two other cases died of the progressed disease at ten months and at four months after surgery, respectively.
CONCLUSION: Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma was concluded to be a treatment option in stage Ib cases with epithelial histology. To evaluate precisely the efficacy of surgery for the disease, a randomized control trial must be organized multi-institutionally.