Malignant pleural mesothelioma: the prognostic significance of different surgical treatments. A retrospective study from a single-institution experience

Backgrounds: Optimal therapy in patients with Malignant Pleural Mesothelioma (MPM) is a matter of debate. Many authors questioned the role of major surgery in the treatment of MPM. We reviewed our recent experience among different treatment options in patients with MPM to assess their prognostic impact. Materials and Methods: From 10/97 to 10/08 326 patients were admitted to our Hospital with a diagnosis of MPM (223 men, 103 women, mean age 64 years, range 32−94). Management options included pleural drainage with/without pleurodesis (24 patients), Video-Assisted Thoracic Surgery (VATS) with/without pleurodesis (195), partial pleurectomy (PL) (27), total PL (8), Extrapleural Pneumonectomy (EPP, 72). The last two treatments were intended as maximal debulking procedures before chemotherapy. Chemotherapy and radiotherapy were used when indicated in exclusive or multimodality protocols. Patients receiving total PL and EPP were compared with those receiving palliative procedures (drainage, VATS or partial PL). Survival analysis was performed using univariate and multivariate (Cox regression) models. Results: Patients receiving PL (partial or total) and EPP were significantly younger than those receiving pleural drainage or VATS (56 vs. 68 years, p = 0.002). Median survival (years) in the different management groups were: pleural drainage (0.97), VATS (0.82), partial PL (1.35), total PL (2.01), EPP (1.73) (p = 0.00001). Two-year survival rates among the groups were: pleural drainage 22%, VATS 18%, partial PL 20%, total PL 50%, EPP 32% (p = 0.00001). A significant survival advantage was observed in patients receiving EPP or total PL vs. those receiving palliative procedures (32% vs.18%, p = 0.0002). In multivariate survival analysis, advanced age was a significant negative prognostic factor (HR 1.02, 95% CI 1.00−1.03, p = 0.007), while EPP or total PL were a significant positive prognostic factor (HR 0.59, 95% CI 0.35−0.99, p = 0.04). Conclusions: In patients with MPM, different treatment options may be offered with either palliative or maximal cytoreductive intent. Patients receiving major surgery are a selected subset of patients younger than those receiving pleural drainage or VATS. A significant survival advantage was observed in patients after total PL or EPP. Our results indicate that surgery with maximal debulking intent offers a significant survival advantage over palliative procedures and should therefore be considered a valuable option in selected patients with MPM.