OPTIMAL MANAGEMENT OF MALIGNANT MESOTHELIOMA AFTER SUBTOTAL PLEURECTOMY - REVISITING THE ROLE OF INTRAPLEURAL CHEMOTHERAPY AND POSTOPERATIVE RADIATION

Malignant pleural mesothelioma (MPM) is a generally fatal disease with no standard treatment. There are encouraging reports using intraperit oneal chemotherapy to treat peritoneal mesotheliomas and intrapleural chemotherapy (IPC) to treat malignant pleural effusions. Our objective was to evaluate the efficacy of IPC after subtotal pleurectomy. Betwe en 1988 and 1992, 20 consecutive patients with diffuse MPM limited to one hemithorax underwent subtotal pleurectomy. Thirteen patients with biopsy-proven MPM known prior to thoracotomy were enrolled in a phase II combined modality protocol consisting of perioperative intrapleural cisplatin (100 mg/m(2)) and ara-C (1,200 mg) after subtotal pleurecto my, followed by systemic cisplatin (50 mg/m(2)/week x 8) and mitomycin -C (8 mg/m(2), days 1 and 36). Seven patients with MPM could not be en rolled because their diagnosis was made post-thoracotomy. These patien ts underwent subtotal pleurectomy with (n = 4) or without (n = 3) adju vant radiation (4,500-5,000 cGy in 3 patients, 2,100 cGy in 1 patient) . One of three patients who developed chemotherapy-related nephrotoxic ity died, the only treatment-related mortality. All 3 patients requiri ng postoperative readmission received LPC. Significant morbidity did n ot occur in patients not receiving chemotherapy. Median survival and t ime to progression were significantly longer in patients not receiving IPC (21 vs. 9 months, P = 0.04; 12 vs. 6 months, P = 0.01). In conclu sion, intrapleural and postoperative systemic chemotherapy resulted in significant toxicity and did not improve survival in our patients who underwent subtotal pleurectomy for MPM. (C) 1995 Wiley-Liss, Inc.