title: Extrapleural pneumonectomy in the treatment of epithelioid malignant pleural mesothelioma: novel prognostic implications of combined N1 and N2 nodal involvement based on experience in 529 patients.
abstract: OBJECTIVE
  We review our 24-year experience with extrapleural pneumonectomy (EPP) in the treatment of epithelioid malignant pleural mesothelioma (MPM).
  
  
  BACKGROUND
  Recent publications, particularly the MARS (Mesothelioma and Radical Surgery) feasibility study by Treasure et al, have questioned the safety and efficacy of EPP for MPM.
  
  
  METHODS
  An institutional review board-approved, prospective, single-center database was retrospectively reviewed. Descriptive statistics and Kaplan-Meier analysis of overall survival are reported.
  
  
  RESULTS
  From 1988 to 2011, a total of 529 patients with epithelioid MPM underwent complete resection by EPP as part of a multimodality strategy. Among these, 131 (25%) were women, and the median age was 59 (range, 17-79) years. Median postoperative hospital stay was 10 (range, 1-101) days. Twenty-six patients (5%) experienced 30-day or in-hospital mortality. Median overall survival was 18 months, with 1-, 3-, 5-, and 10-year survival rates of 67%, 28%, 14%, and 4%, respectively. Outcome by pathologic lymph node status (N, median overall survival) was N0: 224, 26 months; N1: 118, 17 months; N2: 181, 13 months; N3: 5, 7 months; Nx: 1, not evaluable.
  
  
  CONCLUSIONS
  EPP has evolved as an effective method for macroscopic complete resection. This study confirms that lymph node status is significantly correlated with overall survival in patients with epithelioid MPM undergoing EPP and suggests that those with simultaneous involvement of N1 and N2 stations are at increased risk. This observation underscores the need for thorough staging of both N1 and N2 stations and has implications for revision of MPM staging criteria.
authors.affiliation: *Debakey Department of Surgery, Baylor College of Medicine, Houston, TX; and †Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sugarbaker
authors.forename: William G
authors.initials: WG
authors.lastname: Richards
authors.forename: Raphael
authors.initials: R
authors.lastname: Bueno
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D011013:Pneumonectomy / Q000379:methods*; D011379:Prognosis; D012189:Retrospective Studies; D055815:Young Adult