title: Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma.
abstract: BACKGROUND
  To compare the outcomes of two different multimodality regimens involving neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant radiotherapy versus pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy in patients with malignant pleural mesothelioma.
  
  
  METHODS
  Nonrandomized prospective study of patients treated by multimodality therapy and operated on between January 2004 and June 2011. Second-line treatments were administered when appropriate. Survival and prognostic factors were analyzed by the Kaplan Meier method, log rank test, and Cox regression analysis.
  
  
  RESULTS
  Twenty-five consecutive patients received neoadjuvant chemotherapy, 22 underwent EPP, and 17 received adjuvant radiotherapy. Over the same period, 54 consecutive patients underwent P/D and hyperthermic pleural lavage and received prophylactic radiotherapy and adjuvant chemotherapy. The 30-day mortality rate was 4.5%in the EPP group and nil in the P/D group. Fifteen patients (68%) in the EPP group and 15 (27.7%) in the P/D group experienced complications. There were no differences between the EPP and P/D groups for age, sex, histology, pathologic stage, and nodal status. Trimodality therapy was completed by 68%of the patients in the EPP group and 100%in the P/D group. Survival was significantly better in the P/D group: median survival was 23 months versus 12.8 months, 2-year survival was 49%versus 18.2 %, and 5-year survival was 30.1%versus 9%, respectively (p = 0.004). At multivariate analysis, epithelioid histology, P/D, and completeness of resection were independent prognostic factors.
  
  
  CONCLUSIONS
  In our experience, P/D, hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy were superior to neoadjuvant chemotherapy, EPP, and adjuvant radiotherapy.
authors.affiliation: Department of Thoracic Surgery, London and Division of Cancer Studies, King's College London, London, United Kingdom. loic.lang-lazdunski@gstt.nhs.uk
authors.forename: Loïc
authors.initials: L
authors.lastname: Lang-Lazdunski
authors.forename: Andrea
authors.initials: A
authors.lastname: Bille
authors.forename: Rohit
authors.initials: R
authors.lastname: Lal
authors.forename: Paul
authors.initials: P
authors.lastname: Cane
authors.forename: Emma
authors.initials: E
authors.lastname: McLean
authors.forename: David
authors.initials: D
authors.lastname: Landau
authors.forename: Jeremy
authors.initials: J
authors.lastname: Steele
authors.forename: James
authors.initials: J
authors.lastname: Spicer
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008875:Middle Aged; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D011013:Pneumonectomy / Q000379:methods*; D011446:Prospective Studies