Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients

Objectives: Our aim was to identify prognostic variables for long-term post operative survival in trimodality management of malignant pleural mesotheli oma. Methods: From 1980 to 1997, 183 patients underwent extrapleural pneumo nectomy followed by adjuvant chemotherapy and radiotherapy. Results: Forty- three women and 140 men (age range 31-76 years) had a median follow-up of 1 3 months. The perioperative mortality rate was 3.8 % (7 deaths) and the mor bidity, 50%. Survival in the 176 remaining patients was 38% at 2 years and 15% at 5 years (median 19 months). Univariate analysis identified 3 prognos tic variables associated with improved survival: epithelial cell type (52% 2-year survival, 21% 5-year survival, 26-month median survival; P =.0001), negative resection margins (44% at 2 years, 25% at 5 years, median 23 month s; P =.02), and extrapleural nodes without metastases (42% at 2 years, 17% at 5 years, median 21 months; P =.004). Using the Cox proportional hazards, the relative risk of death was calculated for nonepithelial cell type (OR 3.0, CI 2.0-4.5; P < .0001), positive resection margins (OR 1.7, CI 1.2-2.6 ; P =.0082), and metastatic extrapleural nodes (OR 2.0, CI 1.3-3.2;P =.0026 ). Thirty-one patients with 3 positive variables had the best survival (68% 2-year survival, 46% 5-year survival, median 51 months; P =.013). A previo usly published staging system using these variables stratified survival (P <.05). Conclusions: (1) Multimodality therapy including extrapleural pneumo nectomy is feasible in selected patients with malignant pleural mesotheliom as, (2) pre-resectional evaluation of extrapleural nodes may select patient s for radical therapy, (3) microscopic resection margins affect long-term s urvival, highlighting the need for further investigation of locoregional co ntrol, and (4) patients with epithelial, margin-negative, extrapleural node -negative resection had extended survival.