title: Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma.
abstract: OBJECTIVE
  We examined a series of malignant pleural mesothelioma (MPM) patients who underwent radical surgery to explore relationships among comorbidity, postoperative morbidity and survival.
  
  
  METHODS
  A retrospective analysis was carried out of all MPM patients operated on in a single centre from 2000 to 2015. The Charlson Comorbidity Index (CCI) was used to classify patients according to their underlying condition. Postoperative complications were scored according to WHO-derived criteria. Survival comparisons were performed by Cox analysis.
  
  
  RESULTS
  Ninety-one patients underwent extrapleural pneumonectomy (EPP), 47 underwent pleurectomy decortication (PD) and 25 underwent palliative pleurectomy. The mean CCI of PD patients was significantly higher compared with that of EPP patients (P= 0.044). The frequency of grade 3+ complications was similar between EPP and PD (27 vs 26%). However, EPP patients had a 6-fold higher frequency of pleural sepsis (24 vs 4%, P= 0.002) occurring up to 695 days postoperatively. Median overall survival was 19 months (95% CI 13-25) after EPP, 30 months (95% CI 20-35) after PD and 13 months (95% CI 5-32) after palliative pleurectomy. At multivariate analysis, CCI (P< 0.001), histology (P= 0.014) and pleural sepsis (P= 0.001), but not complete resection, were significantly associated with survival. There was a trend in favour of PD over palliative resection after adjusting for histology and CCI.
  
  
  CONCLUSIONS
  The CCI is an independent predictor of survival in MPM patients undergoing radical surgery. Owing to its significant frequency and adverse impact, pleural sepsis may contribute to a reduced life expectancy after EPP. Surgical treatment of MPM remains debatable.
authors.affiliation: Department of Thoracic Surgery, University Hospital Borgo Trento, Verona, Italy maurizio.infante@ospedaleuniverona.it.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Infante
authors.affiliation: Clinical Research Unit, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Morenghi
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Bottoni
authors.affiliation: Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Zucali
authors.affiliation: Department of Pathology, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Daoud
authors.initials: D
authors.lastname: Rahal
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Morlacchi
authors.affiliation: Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Anna Maria
authors.initials: AM
authors.lastname: Ascolese
authors.affiliation: Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Fiorenza
authors.initials: F
authors.lastname: De Rose
authors.affiliation: Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Pierina
authors.initials: P
authors.lastname: Navarria
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Crepaldi
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Testori
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Voulaz
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Errico
authors.affiliation: Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Perrino
authors.affiliation: Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Scorsetti
authors.affiliation: Nuclear Medicine, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy.
authors.forename: Arturo
authors.initials: A
authors.lastname: Chiti
authors.affiliation: Oncology and Hematology, Humanitas Clinical and Research Center, Humanitas University, Rozzano (Milan), Italy.
authors.forename: Armando
authors.initials: A
authors.lastname: Santoro
authors.affiliation: Department of Thoracic Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Alloisio
mesh_terms: D000368:Aged; D015897:Comorbidity; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D008297:Male; D008654:Mesothelioma / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D010997:Pleural Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery; D011013:Pneumonectomy; D011183:Postoperative Complications / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016019:Survival Analysis
keywords: Comorbidity; Extrapleural pneumonectomy; Malignant pleural mesothelioma; Palliative pleurectomy; Pleurectomy decortication