Archive for the ‘Pleural Mesothelioma’ Category


Multimodality Therapy for Malignant Pleural Mesothelioma: ConclusionPrevious staging systems for mesothelioma are of limited practical value because they are based on treatment strategies that do not include stratification of survival. The most commonly used staging system was proposed by Butchart et al in 1976, based on the treatment of 29 patients who underwent pleural pneumonectomy. According to this system, stage I disease is confined to the capsule of the pleural envelope, lung, pericardium, and diaphragm; stage II disease includes tumors extending into the chest wall, esophagus, heart, or contralateral pleura, with or without thoracic lymph node involvement; stage III disease includes tumors extending through the diaphragm into the peritoneum with positive extrathoracic lymph nodes; and stage IV disease classifies rare patients presenting with blood-borne metastases. This system does not reliably predict survival probability by stage.
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  • Survival was not affected by gross residual tumor in the specimen, age, gender, cigarette smoking, asbestos exposure, length of operation, side of tumor, microscopically compromised margins (Fig 3), or neoplasia involving (but not fully penetrating the full thickness of) either the pericardium or diaphragm. Microscopic invasion of tumor through the diaphragm was significantly associated with poorer survival (median, 11 months; n = 14), regardless of cell type or node status.
    A revised mesothelioma staging system based on an earlier analysis of a subset of these patients (n=52) has been published. Stage I indicates disease that is resectable by pleurectomy or extrapleural pneumonectomy. Stage II includes patients with involved lymph nodes detected on MRI, at mediastinoscopy, or at thoracotomy. Stage III (combines Butchart stages II and III) tumors extend into the mediastinum or across the diaphragm and are therefore considered unresectable. Stage IV includes patients presenting with evidence of extrathoracic metastasis.
    Survival in the entire cohort (n=120) was significantly stratified by stage using this revised system (Fig 4). Median survival rates for patients classified as having stage I (n=57), II (n=43), or stage III (n=14) disease by this system were 22, 17, and 11 months, respectively (p=0.04). canadian-familypharmacy.com

    Discussion
    In appropriately selected patients, extrapleural pneumonectomy with adjuvant chemotherapy and radiotherapy is safe and effective treatment for malignant pleural mesothelioma. Overall median survival (21 months, Fig 1) of patients receiving this trimodality therapy is superior to that obtained with single-modality therapy. Nodal involvement, cell type, and transdiaphragmatic invasion are prognostic factors that stratify survival of patients treated in this manner. The results described herein validate a revised staging system that is based on resectability and nodal involvement.

    Figure 3. Kaplan-Meier survival curve for all patients with positive vs negative surgical resection margins. Survival did not depend on margin status (p=not significant). Reprinted with permission from Sugarbaker et al.

    Figure 3. Kaplan-Meier survival curve for all patients with positive vs negative surgical resection margins. Survival did not depend on margin status (p=not significant). Reprinted with permission from Sugarbaker et al.

    Figure 4. Kaplan-Meier survival curve demonstrating significant stratification of survival when all patients are classified as having stage I, II, or III disease according to our previously proposed staging system. Reprinted with permission from Sugarbaker et al.

    Figure 4. Kaplan-Meier survival curve demonstrating significant stratification of survival when all patients are classified as having stage I, II, or III disease according to our previously proposed staging system.’ Reprinted with permission from Sugarbaker et al.

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  • Multimodality Therapy for Malignant Pleural Mesothelioma: ResultsMedian length of hospital stay following extrapleural pneumonectomy was 9 days (range, 5 to 101 days). Perioperative (30-day) mortality was 5%, resulting from myocardial infarction (two patients), pulmonary embolus (two), respiratory failure (one), and cardiac herniation through the pericardial defect (one). Morbidity was 22%. Fifteen patients (12.5%) experienced one or more of the following major complications: hemorrhage (four patients), respiratory failure (four), pneumonia (five), disrupted diaphragmatic patch (one), perforated duodenal ulcer (two), empyema (one), upper GI tract bleed (one), and deep venous thrombosis (three). cialis professional
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  • Thus, in our study, candidate patients were evaluated on the basis of spirometry, oximetry, arterial blood gases, chest radiograph and CT, chest MRI (after 1988), ventilation-perfusion scan (if FEV1 was <1 L), and echocardiography. Patients without medical contraindications whose tumor was clinical stage I according to Butchart et al and considered completely resectable were candidates for trimodality therapy if they had an Eastern Cooperative Oncology Group performance status of 0 or 1 and normal renal and hepatic function. Patients were excluded if they exhibited compromised cardiac function (ejection fraction <45%), preoperative partial pressure of C02 >45 mm Hg, room air partial pressure of 02 <65 mm Hg or predicted postoperative FEVj of <1 L, or mediastinal or transdia-phragmatie invasion on MRI. (more…)

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  • Multimodality Therapy for Malignant Pleural Mesothelioma

    Feb 26, 2014 Author: Walter Mcneil | Filed under: Pleural Mesothelioma

    Multimodality Therapy for Malignant Pleural MesotheliomaMalignant pleural mesothelioma, a rare disease whose etiology is tied to asbestos exposure, has been steadily increasing in incidence despite industrial regulation of asbestos during the 1960s. As many as 3,000 new cases are expected to be diagnosed in the United States in 1997. The rising incidence can be attributed to the disease’s long exposure-to-diagnosis interval. Left untreated, patients survive a median of 4 to 12 months.
    The failure of single-modality and bimodality therapy to improve the survival of patients with malignant pleural mesothelioma led us to evaluate a trimodality approach of extrapleural pneumonectomy followed by combination che-moradiotherapy. Our rationale behind using extrapleural pneumonectomy as opposed to pleurectomy was that a complete or near-complete resection would be expected to improve survival in patients with this primarily locally recurring disease, and that high-dose radiotherapy could be administered without concern for radiation pneumonitis. (more…)

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