A Review of Dr. Sugarbaker's Results Using Tri-Modal Therapy on 183 Patients from 1980 to 1997
The following abstract is from an article authored by Dr. David Sugarbaker of the Brigham and Womens Hospital in Boston. It is noteworthy that the patients with epithelial tumors generally have a significantly longer mean survival than the patients with mixed type/sarcomatous tumor.
Resection Margins, N2 status and Cell type Determine Survival in Trimodality Therapy of Malignant Pleural Mesothelioma (MPM): Results in 183 Patients
Objectives: We review our experience with extrapleural pneumonectomy (EPP) in the multimodality management of MPM.
Methods: From 1980 to 1997, 183 consecutive patients underwent trimodality therapy involving EPP followed by adjuvant chemotherapy and radiotherapy. Standardized systematic pathologic analysis was undertaken.
Results: The cohort included 43 women and 140 men with a mean age of 57 years (range 31-76) and a median follow-up interval of 13 months. Overall survival was 36% at 2 yrs and 14% at 5 yrs (median 17 mo.). There were seven perioperative deaths (3.8% mortality). Factors affecting long-term survival were evaluated in 176 patients surviving surgery (among these, survival was 38% at 2 yrs and 15% at 5 yrs; median 19 mo.). As indicated in the table below, lack of N2 nodal involvement, negative resection margins and epithelial histology were associated with improved survival. Factorial grouping by N2 status and resection margins significantly stratified survival among all patients surviving surgery (p<0.02), and among those with epithelial histology (p<.02). Thirty-one patients with epithelial tumors, negative resection margins and without N2 involvement had a 51 mo. median survival (68% 2-yr, 46% 5-yr). A clinico-pathologic staging system previously published stratified survival (p<0.05; see table).
| Variable |
N |
2-Year |
5-Year |
Median(months) |
P Value |
| Epithelial |
103 |
52% |
21% |
26 |
0.0001 |
| Mixed/Sarcom |
73 |
16% |
0% |
13 |
|
| Margins(+) |
110 |
33% |
9% |
15 |
0.02 |
| Margins(-) |
66 |
44% |
25% |
23 |
|
| N2(+) |
40 |
23% |
0% |
14 |
0.004 |
| N2(-) |
136 |
42% |
17% |
21 |
|
| Epithel.N2(+) |
21 |
38% |
0% |
20 |
0.052 |
| Epithel.N2(-) |
82 |
56% |
24% |
34 |
|
| Epithel.N2(+) Marg(+) |
12 |
29% |
0% |
14 |
0.013 |
| Epithel.N2(+) Marg(-) |
9 |
43% |
0% |
22 |
|
| Epithel.N2(-) Marg(+) |
51 |
49% |
14% |
22 |
|
| Epithel.N2(-) Marg(-) |
31 |
68% |
46% |
51 |
|
| StageI |
66 |
53% |
20% |
25 |
0.048 |
| StageII |
41 |
44% |
14% |
20 |
|
| StageIII |
69 |
17% |
14% |
16 |
|
These data support the following conclusions:
- Multimodality therapy including EPP is feasible in selected patients with MPM,
- Microscopic resection margins affect long-term survival, pointing to the need for further investigation of local-regional control strategies,
- Mediastinoscopy to evaluate N2 nodes is recommended, and
- Patients with epithelial, margin-negative, N2-negative resection enjoy long-term survival.
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