title: Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients.
abstract: OBJECTIVE
  Our aim was to identify prognostic variables for long-term postoperative survival in trimodality management of malignant pleural mesothelioma.
  
  
  METHODS
  From 1980 to 1997, 183 patients underwent extrapleural pneumonectomy followed by adjuvant chemotherapy and radiotherapy.
  
  
  RESULTS
  Forty-three women and 140 men (age range 31-76 years) had a median follow-up of 13 months. The perioperative mortality rate was 3.8% (7 deaths) and the morbidity, 50%. Survival in the 176 remaining patients was 38% at 2 years and 15% at 5 years (median 19 months). Univariate analysis identified 3 prognostic variables associated with improved survival: epithelial cell type (52% 2-year survival, 21% 5-year survival, 26-month median survival; P =.0001), negative resection margins (44% at 2 years, 25% at 5 years, median 23 months; P =.02), and extrapleural nodes without metastases (42% at 2 years, 17% at 5 years, median 21 months; P =.004). Using the Cox proportional hazards, the relative risk of death was calculated for nonepithelial cell type (OR 3.0, CI 2.0-4.5; P <.0001), positive resection margins (OR 1.7, CI 1.2-2.6; P =.0082), and metastatic extrapleural nodes (OR 2.0, CI 1.3-3.2; P =.0026). Thirty-one patients with 3 positive variables had the best survival (68% 2-year survival, 46% 5-year survival, median 51 months; P =.013). A previously published staging system using these variables stratified survival (P <.05).
  
  
  CONCLUSIONS
  (1) Multimodality therapy including extrapleural pneumonectomy is feasible in selected patients with malignant pleural mesotheliomas, (2) pre-resectional evaluation of extrapleural nodes may select patients for radical therapy, (3) microscopic resection margins affect long-term survival, highlighting the need for further investigation of locoregional control, and (4) patients with epithelial, margin-negative, extrapleural node-negative resection had extended survival.
authors.affiliation: Division of Thoracic Surgery and the Department of Pathology, Brigham and Women's Hospital, Boston, Mass 02115, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Sugarbaker
authors.forename: R M
authors.initials: RM
authors.lastname: Flores
authors.forename: M T
authors.initials: MT
authors.lastname: Jaklitsch
authors.forename: W G
authors.initials: WG
authors.lastname: Richards
authors.forename: G M
authors.initials: GM
authors.lastname: Strauss
authors.forename: J M
authors.initials: JM
authors.lastname: Corson
authors.forename: M M
authors.initials: MM
authors.lastname: DeCamp
authors.forename: S J
authors.initials: SJ
authors.lastname: Swanson
authors.forename: R
authors.initials: R
authors.lastname: Bueno
authors.forename: J M
authors.initials: JM
authors.lastname: Lukanich
authors.forename: E H
authors.initials: EH
authors.lastname: Baldini
authors.forename: S J
authors.initials: SJ
authors.lastname: Mentzer
mesh_terms: D000328:Adult; D000368:Aged; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D011013:Pneumonectomy; D011379:Prognosis; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome