title: Three decades of experience in the surgical multi-modality management of pleural mesothelioma.
abstract: BACKGROUND
  Optimal management of diffuse malignant pleural mesothelioma (DMPM) remains unclear. We report our 30-year surgical experience with DMPM with emphasis on surgical procedure and post-operative adjuvant therapy.
  
  
  METHODS
  During the period of the study, 217 patients with DMPM were referred for surgical opinion. Patients who only had pleural biopsies were excluded (n=78). Consecutive patients who underwent surgical treatment were included (n=139). Surgical options were extra-pleural pneumonectomy (EPP) for Butchart stage I disease in clinically fit patients (n=49) or pleurectomy/decortication in patients who were either not fit for EPP or had advanced disease (Butchart stage II and III) or both (n=90). Post-operative adjuvant therapy included either chemotherapy, radiotherapy, both or none.
  
  
  RESULTS
  The median follow-up was 10.0 months. The longest survival (median 26.0 months, IQR: 11.14-40.9 months) occurred in the pleurectomy/decortication group who received both post-operative chemotherapy and radiotherapy (n=24) (p<0.001). EPP whether or not combined with adjuvant therapy provided no significant survival advantage in comparison to pleurectomy/decortication (overall median survival 10.3 months vs 10.1 months, p=0.09). On univariate analysis, pleurectomy/decortication combined with chemotherapy and radiotherapy was the strongest predictor of prolonged survival (Hazard Ratio=3.6). Multivariate analysis with the inclusion of histological type, surgical procedure and type of adjuvant therapy, EPP without adjuvant therapy was an independent risk-factor for decreased survival (Hazard Ratio=9.2).
  
  
  CONCLUSIONS
  In this series, cytoreductive surgery combined with post-operative adjuvant therapy provided better survival despite either advanced disease or surgically less fit patients. Thus, pleurectomy/decortication may be the procedure of choice, given that neither surgical procedure (EPP or PD) is not curative.
authors.affiliation: Heart and Lung Centre, New Cross Hospital, Wolverhampton, WV10 0QP, United Kingdom. HeymanLuckraz@aol.com
authors.forename: Heyman
authors.initials: H
authors.lastname: Luckraz
authors.forename: Mesbah
authors.initials: M
authors.lastname: Rahman
authors.forename: Nishith
authors.initials: N
authors.lastname: Patel
authors.forename: Adam
authors.initials: A
authors.lastname: Szafranek
authors.forename: Allen R
authors.initials: AR
authors.lastname: Gibbs
authors.forename: Eric G
authors.initials: EG
authors.lastname: Butchart
mesh_terms: D000368:Aged; D017024:Chemotherapy, Adjuvant; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D008875:Middle Aged; D010997:Pleural Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D011013:Pneumonectomy / Q000379:methods*; D018714:Radiotherapy, Adjuvant; D016896:Treatment Outcome