title: Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma.
abstract: OBJECTIVE
  Malignant mesothelioma is increasing in incidence and no current therapy significantly prolongs survival. Previous surgical strategies involved high-risk open procedures without achieving histologically clear resection margins. We present the results of VATS debulking pleurectomy-decortication in advanced disease.
  
  
  METHODS
  A consecutive series of patients with suspected malignant mesothelioma underwent thoracoscopic assessment to determine the feasibility of decortication, where this was not possible a biopsy alone was taken. Post-operative radiotherapy was administered to port sites, but no other adjuvant therapy was given. The two groups (biopsy only and pleurectomy-decortication) were composed of patients with histologically confirmed mesothelioma [28 and 51 patients, respectively]. The primary endpoint was comparison of actuarial patient survival. Secondary endpoints included post-operative air leak and duration of hospital stay.
  
  
  RESULTS
  The overall actuarial survival was 288 days and 67% of patients had died at the time of data analysis. The groups were matched for patient and tumour-related characteristics including age (66, 64 years, p=0.39) and tumour stage (median IMIG stage 3 [IQR 2-3] both groups, p=0.54). The biopsy only group had fewer air leaks (57, 84%, p=0.01) and a shorter hospital stay (4, 8 days, p=0.03). However, the pleurectomy-decortication group had favourable actuarial survival relative to the biopsy only group (416, 127 days, p<0.001). Multivariate analysis showed early stage (p<0.001), absence of pre-operative fever (p=0.03) and pleurectomy-decortication (p<0.001) as independent predictors of survival.
  
  
  CONCLUSIONS
  VATS pleurectomy-decortication is feasible in the majority of cases and independently improves survival for patients with advanced malignant mesothelioma.
authors.affiliation: Department of Thoracic Surgery, Papworth Hospital, Cambridge, UK. jameschalstead@yahoo.co.uk
authors.forename: J C
authors.initials: JC
authors.lastname: Halstead
authors.forename: E
authors.initials: E
authors.lastname: Lim
authors.forename: R M
authors.initials: RM
authors.lastname: Venkateswaran
authors.forename: S C
authors.initials: SC
authors.lastname: Charman
authors.forename: M
authors.initials: M
authors.lastname: Goddard
authors.forename: A J
authors.initials: AJ
authors.lastname: Ritchie
mesh_terms: D000206:Actuarial Analysis; D000368:Aged; D005240:Feasibility Studies; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016016:Proportional Hazards Models; D016019:Survival Analysis; D020775:Thoracic Surgery, Video-Assisted; D016896:Treatment Outcome