Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.
OBJECTIVE
To investigate the incidence and management of postoperative complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.


METHODS
Patients with histologically proven mesothelioma of clinical stages T1-3, N0-2, M0 and considered to be completely resectable received neoadjuvant chemotherapy (cisplatin+gemcitabine or cisplatin+pemetrexed) followed by extrapleural pneumonectomy and postoperative radiotherapy. The incidence and management of postoperative complications in general and of bronchopleural fistula and postpneumonectomy-empyema in particular were analyzed. Univariate analysis was performed to identify prognostic factors [sex, age, side of operation, weight loss, smoking, chemotherapy, EORTC-score (European Organization for Research and Treatment of Cancer-classification) and duration of operation].


RESULTS
Between 1st May 1999 and 15th August 2005, 63 patients underwent complete extrapleural pneumonectomy after neoadjuvant chemotherapy. Postoperative complications were observed in 39 cases (62%) and 2 patients died within 30 days (3.2%). Postpneumonectomy-empyema occurred in 15.8% of the patients (n=10), six with a bronchopleural fistula on the right side. All empyemas were treated successfully. Five patients developed chylothorax (7.9%) and four patients had complications due to a patch failure: cardiac herniation (n=2), restriction of cardiac output (n=1) or gastric herniation (n=1). Patients with higher EORTC-score presented significantly more postoperative complications (p=0.03). A longer duration of surgery tended to be associated with a higher incidence of postoperative complications, especially of empyemas.


CONCLUSIONS
Extrapleural pneumonectomy after neoadjuvant chemotherapy can be performed with mortality rates comparable to standard pneumonectomies. Complications are frequent but can be successfully managed; the EORTC-score seems to be a predictor for postoperative complications.
Division of Thoracic Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
Isabelle
I
Opitz
Peter
P
Kestenholz
Didier
D
Lardinois
Michael
M
Müller
Valentin
V
Rousson
Didier
D
Schneiter
Rolf
R
Stahel
Walter
W
Weder
D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001983:Bronchial Fistula / Q000209:etiology; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000008:administration & dosage; D003841:Deoxycytidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D005260:Female; D005402:Fistula / Q000209:etiology; D005971:Glutamates / Q000008:administration & dosage; D006147:Guanine / Q000008:administration & dosage / Q000031:analogs & derivatives; D006801:Humans; D007432:Intraoperative Period; D007902:Length of Stay; D008297:Male; D008654:Mesothelioma / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D000068437:Pemetrexed; D010995:Pleural Diseases / Q000209:etiology; D010997:Pleural Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D011013:Pneumonectomy / Q000009:adverse effects*; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D000093542:Gemcitabine
D005971:Glutamates; D000068437:Pemetrexed; D003841:Deoxycytidine; D006147:Guanine; D002945:Cisplatin; D000093542:Gemcitabine