Multimodal therapy of epithelioid pleural mesothelioma: improved survival by changing the surgical treatment approach

Laura V Klotz; Hans Hoffmann; Rajiv Shah; Florian Eichhorn; Christiane Gruenewald; Elena L Bulut; Raffaella Griffo; Thomas Muley; Petros Christopoulos; Philip Baum; Peter Huber; Seyer Safi; Marc Kriegsmann; Michael Thomas; Helge Bischoff; Hauke Winter; Martin E Eichhorn

doi:10.21037/tlcr-22-199

Multimodal therapy of epithelioid pleural mesothelioma: improved survival by changing the surgical treatment approach

Transl Lung Cancer Res. 2022 Nov;11(11):2230-2242. doi: 10.21037/tlcr-22-199.

Authors

Laura V Klotz^{1

2}, Hans Hoffmann³, Rajiv Shah^{2

4}, Florian Eichhorn^{1

2}, Christiane Gruenewald¹, Elena L Bulut¹, Raffaella Griffo^{1

2}, Thomas Muley^{2

5}, Petros Christopoulos^{2

4}, Philip Baum¹, Peter Huber⁶, Seyer Safi³, Marc Kriegsmann^{2

7}, Michael Thomas^{2

4}, Helge Bischoff⁴, Hauke Winter^{1

2}, Martin E Eichhorn^{1

2}

Affiliations

¹ Department of Thoracic Surgery, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.
² Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
³ Division of Thoracic Surgery, Technical University of Munich, Munich, Germany.
⁴ Department of Thoracic Oncology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.
⁵ Translational Research Unit, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.
⁶ Department of Molecular and Radiation Oncology, German Cancer Research Center and University of Heidelberg, Heidelberg, Germany.
⁷ Department of Pathology, University of Heidelberg, Heidelberg, Germany.

Abstract

Background: The exact role and type of surgery for malignant pleural mesothelioma (MPM) remains controversial. This study aimed at analyzing a 20-year single center perioperative experience in MPM surgery at our high-volume thoracic surgery center and comparing the overall survival after trimodal extrapleural pneumonectomy (EPP) and extended pleurectomy and decortication combined with hyperthermic intrathoracic chemoperfusion (EPD/HITOC) and adjuvant chemotherapy with that after chemotherapy (CTx) alone.

Methods: Patients with epithelioid MPM treated with neoadjuvant chemotherapy, EPP and adjuvant radiotherapy within a trimodal concept or EPD/HITOC in combination with adjuvant chemotherapy between 2001 and 2018 were included in this retrospective analysis. Surgical cohorts were compared to patients treated with standard chemotherapy.

Results: Overall, 182 patients (69 EPP, 57 EPD/HITOC, 56 CTx) were analyzed. Due to occupational exposure to asbestos for most of the patients, 154 patients (84.6%) were male. The patients in the surgical cohorts were significantly younger than those in the CTx cohort. There was no significant difference between the proportion of patient age and side. The median overall survival of the EPD/HITOC cohort with 38.1 months was significantly longer than that of the EPP and CTx cohorts (24.0 and 15.8 months). Better survival was significantly associated with an ECOG 0 performance status, age below 70 years, and negative lymph node status. In the multivariate analysis, EPD/HITOC was significantly associated with improved overall survival. Perioperative morbidity was lower in the EPD/HITOC group than in the EPP cohort.

Conclusions: EPD/HITOC is feasible and safe for localized epithelioid pleural mesothelioma. Changing the surgical approach to a less radical lung-sparing technique may improve overall survival compared to trimodal EPP.

Keywords: Pleural mesothelioma; chemoperfusion; cytoreductive surgery; decortication; extrapleural pneumonectomy.