ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;85:1206-1210. doi:10.1016/j.athoracsur.2007.11.065
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Marc de Perrot
Masaki Anraku
Thomas K. Waddell
Andrew F. Pierre
Gail Darling
Shaf Keshavjee
Michael R. Johnston
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by de Perrot, M.
Right arrow Articles by Johnston, M. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by de Perrot, M.
Right arrow Articles by Johnston, M. R.
Related Collections
Right arrow Pleura

Original Articles: General Thoracic

Risk Factors for Major Complications After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma

Marc de Perrot, MDa,*, Karen McRae, MDb, Masaki Anraku, MDa, Keyvan Karkouti, MDb, Thomas K. Waddell, MDa, Andrew F. Pierre, MDa, Gail Darling, MDa, Shaf Keshavjee, MDa, Michael R. Johnston, MDa

a Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
b Department of Anesthesia, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada

Accepted for publication November 26, 2007.

* Address correspondence to Dr de Perrot, Division of Thoracic Surgery, Toronto General Hospital, 9N-961, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada (Email: marc.deperrot{at}uhn.on.ca).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Factors associated with increased risk of major complications after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma are not well characterized; in particular, the risks of induction chemotherapy and red blood cell (RBC) transfusion have not been well defined.

Methods: We reviewed our experience with 62 consecutive EPP (28 right sided) performed in our institution for malignant pleural mesothelioma between January 1993 and May 2007. A total of 44 patients underwent induction chemotherapy with cisplatin-based therapy.

Results: The majority of patients (88%) received RBC transfusions (median, 4 units; range, 0 to 18 units). Patients undergoing induction chemotherapy had lower preoperative hemoglobin (122 ± 16 g/L versus 134 ± 15 g/L in the remaining patients, p = 0.02) and received more RBC transfusions (5.1 ± 3.5 units versus 2.1 ± 2.3 units in the remaining patients, p = 0.007). Twenty-two patients (35%) experienced major postoperative complications and 4 of them died (6.5%). Patients experiencing major complications were older (60 ± 8 years versus 56 ± 12 years, respectively; p = 0.2) and received more RBC transfusions (5.8 ± 4.3 units versus 3.7 ± 2.7 units, respectively; p = 0.02). Major complications occurred more frequently after right-sided EPP than after left-sided EPP (54% versus 21%, p = 0.007). Induction chemotherapy had no impact on the risk of major complications (p = 0.5). Transfusion of more than 4 units of RBC (p = 0.01) and right-sided EPP (p = 0.01) were associated with increased risk of major complications after EPP in multivariate analysis.

Conclusions: Right EPP and more than 4 units of RBC transfusion are associated with increased risk of major complications. Although patients undergoing induction chemotherapy received more RBC transfusions, induction chemotherapy did not directly impact the risk of major complications.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Malignant pleural mesothelioma (MPM) is an uncommon neoplasm associated with a median survival of approximately 10 months from the time of histologic diagnosis [1]. Extrapleural pneumonectomy (EPP) has been performed in selected patients with MPM, but its role has remained limited because of the morbidity and mortality associated with the procedure. Recent series have demonstrated a dramatic reduction in the operative mortality since the 1970s, with a 30-day mortality ranging between 3% and 8% [2–4]. However, despite the improvement in operative mortality, the rate of major postoperative complications remains high. In addition, induction chemotherapy has been increasingly used before EPP with the hope of improving long-term survival, but its administration before surgery may increase the risk of postoperative complications [5–7]. We, therefore, performed a retrospective analysis of patients undergoing EPP for MPM in our institution to identify factors associated with an increased risk of postoperative complications.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
A total of 62 consecutive patients with biopsy-proven MPM underwent EPP in our institution between January 1993 and May 2007. Most patients (70%, n = 45) underwent surgery between January 2001 and May 2007. A retrospective chart review was performed after approval by the Institutional Review Board. The Institutional Review Board approval waived the need for patient consent to perform the study.

All patients were evaluated preoperatively by chest radiograph, contrast-enhanced computed tomography (CT) scan of the chest and abdomen, spirometry and ventilation-perfusion scan. Magnetic resonance imaging (MRI) was used in selected cases. Brain CT or MRI as well as bone scan were performed if clinically indicated. Resectability was defined by tumor confined to one hemithorax with no evidence of mediastinal organ, spine, diffuse chest wall involvement, or transdiaphragmatic extension. Positron emission tomography scan was not available in our institution until recently and was not performed for any of these patients. Mediastinoscopy was always performed if the mediastinal lymph nodes were larger than or equal to 1.5 cm in their greatest diameter on the chest CT. If lymph nodes were smaller than 1.5 cm in their largest diameter, mediastinoscopy was performed on a case-by-case basis, mainly according to the surgeon’s preference.

Extrapleural pneumonectomy included en bloc resection of the lung, parietal pleura, ipsilateral diaphragm, and ipsilateral pericardium. Previous biopsy sites were removed with a limited chest wall resection. Systematic mediastinal lymph node dissection or sampling was performed in all patients to allow accurate surgical staging of the disease. Paraesophageal, peridiaphragmatic, and subcarinal nodal stations were examined for tumors located on the right and on the left side. Additionally, paratracheal nodes were examined for right-sided tumors, and aortopulmonary window and para-aortic nodes were sampled for left-sided tumors. Tumors were staged according to the staging system developed by the International Mesothelioma Interest Group and published by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) [8].

Postoperative deaths included all patients who died within 30 days of surgery or during the same hospitalization. Postoperative complications were defined as complications within 30 days of surgery or during the same hospital stay. Major complications were defined by complications of grade 3 or higher according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) 3.0 guidelines.

The number of units of red blood cell (RBC) transfusion was recorded during the hospital stay. Indications for blood transfusions were hemoglobin levels of less than 80 g/L, or hemoglobin levels between 80 and 100 g/L and a history of ischemic heart disease or clinical intolerance to anemia with tachycardia and systemic hypotension. Estimated blood loss was recorded intraoperatively.

Results are presented in absolute number and percentage, median and range, or mean ± SD. For statistical analysis, major complications were grouped as a composite endpoint because of the low incidence of each individual complication. Variables tested for their potential impact on major postoperative complications and survival were induction chemotherapy (yes versus no), age greater than 60 years old (yes versus no), sex (male versus female), transfusions of more than 4 units of red blood cells (yes versus no), stage (I and II versus III and IV), and side of surgery (right versus left). Categorical variables were compared by {chi}2 analysis and numerical variables by Student t test. Overall survival was estimated using the method of Kaplan-Meier. Differences in survival were tested for significance by the log-rank test. Multivariate analysis was assessed by logistic regression analysis for categorical variables and by the Cox proportional hazards stepwise model for numerical variables. Statview V (Abacus Concepts, Berkeley, California) was used for all analyses. A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Most patients were males and presented with epithelial cell type (Table 1). A total of 22 patients (35%) presented with major postoperative complications and 4 (6.5%) died postoperatively (Table 2). The causes of death were bronchopleural fistula with empyema (n = 1), cardiac arrhythmia (n = 1), cardiac herniation (n = 1), and aspiration pneumonia (n = 1). All deaths occurred after right EPP. The operative mortality was therefore 14% (4 of 28) after right EPP and 0% after left EPP (p = 0.02).


View this table:
[in this window]
[in a new window]

  		Table 1 Patient Characteristics (n = 62)
 

View this table:
[in this window]
[in a new window]

  		Table 2 Postoperative Complications a
 
Eight patients required reoperation for hemothorax (n = 1), chylothorax (n = 1), cardiac herniation due to dehiscence of the pericardial patch (n = 1), abdominal herniation due to dehiscence of the diaphragmatic patch (n = 2), esophageal perforation (n = 1), and empyema requiring a Clagett window (n = 1). One patient presenting with a small bronchopleural fistula (about 5 mm) and no empyema at 4 weeks postoperatively underwent immediate closure of the fistula with a pectoralis major muscle flap with no further complication. Six patients required reintubation or prolonged mechanical ventilation and 2 required a temporary tracheostomy during their hospital stay.

The rate of major complications was significantly higher after right EPP than after left EPP (Fig 1). Patients experiencing major complications were also older (60 ± 8 years versus 56 ± 12 years, respectively; p = 0.2) than patients who experienced minor or no complications.


Figure 1
View larger version (6K):
[in this window]
[in a new window]

  		Fig 1. The rate of major complications was 54% after right extrapleural pneumonectomy (EPP) and 21% after left EPP (p = 0.007).

 
A total of 44 patients received two or three cycles of cisplatin-based doublet induction chemotherapy. Cisplatin was combined with vinorelbine (n = 20), pemetrexed (n = 18), adriamycin (n = 3), or gemcitabine (n = 3). Two patients had pulmonary emboli during chemotherapy and required inferior vena cava filter insertion before their EPP. No recurrent pulmonary emboli were observed at the time of surgery and thereafter in these 2 patients.

The mean preoperative hemoglobin was 125 ± 17 g/L, but was significantly lower in patients who underwent induction chemotherapy when compared with patients who did not (122 ± 16 g/L versus 134 ± 15 g/L, respectively; p = 0.02). The majority of patients (88%) received RBC transfusions (median, 4 units; range, 0 to 18 units; Fig 2). Estimated intraoperative blood loss ranged between 900 and 6,500 mL with a median of 2,000 mL. Patients undergoing induction chemotherapy received more RBC transfusions than patients who did not have induction therapy (5.8 ± 4.3 units versus 3.7 ± 2.7 units, respectively; p = 0.02). Patients experiencing major complications also received more RBC transfusions (5.8 ± 4.4 units versus 3.7 ± 2.7 units, respectively; p = 0.02) than patients who experienced minor or no complications.


Figure 2
View larger version (9K):
[in this window]
[in a new window]

  		Fig 2. Red blood cell transfusions in patients undergoing extrapleural pneumonectomy.

 
Factors associated with increased risk of major postoperative complications after multivariate analysis were right-sided EPP and more than 4 units of RBC transfusion (Table 3). Patient’s age, sex, stage of disease, and induction chemotherapy was not associated with an increased risk of major postoperative complication.


View this table:
[in this window]
[in a new window]

  		Table 3 Risk Factors for Major Complications
 
The overall 3- and 5-year survival was 27% and 23%, respectively. There was no significant difference in survival between right and left EPP, with a 3-year survival of 23% and 30%, respectively (p = 0.8). However, survival was significantly worse in patients receiving more than 4 units of RBC transfusion (3-year survival of 14% versus 36% in remaining patients, p = 0.03; Fig 3). Cox proportional hazards analysis demonstrated that the impact of RBC transfusion on long-term survival remained close to statistical significance after adjusting for other variables such as stage of disease, patient’s age and sex, side of surgery, and induction chemotherapy (Table 4).


Figure 3
View larger version (9K):
[in this window]
[in a new window]

  		Fig 3. Impact of red blood cell (RBC) transfusions on long-term survival. (Solid line = <4 units RBC transfusion; broken line = >4 units RBC transfusion.)

 

View this table:
[in this window]
[in a new window]

  		Table 4 Impact of Red Blood Cell (RBC) Transfusion on Survival in Cox Proportional Hazards Analysis
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
This study confirms that EPP can be performed with a low operative mortality. However, major complications still occur in a large proportion of patients. The overall incidence of major complications was 35%, with an operative mortality of 6.5% in our experience, confirming the results from other series recently published in the literature [2–4].

The rate of major complications and postoperative deaths was significantly higher after right-sided EPP than after left-sided EPP. Major complications developed in more than 50% of patients undergoing right-sided EPP, and all 4 postoperative deaths reported in our series occurred after right-sided EPP. Stewart and coworkers [3] made similar observations in their analysis of risk factors for postoperative morbidity after EPP. They observed that right EPP was associated with an increased risk of pneumonia and higher rate of admission to the intensive care unit [3].

Opitz and colleagues [4] reported a series of 63 patients undergoing EPP after induction chemotherapy and observed an incidence of postpneumonectomy empyema of 16%. We did not observe an increased rate of postpneumonectomy empyema despite induction chemotherapy in our series. In 2 patients (4%), an empyema developed after EPP, one of them being related to bronchopleural fistula. The reason for such a difference in the incidence of postpneumonectomy empyema between both series is unclear. We do perform frequent irrigation of the pleural space with povidone-iodine intraoperatively and maintain the patients on antibiotics until removal of the chest tube. The chest tube is kept for 24 to 72 hours and is usually removed once the drainage from the postpneumonectomy space becomes serous.

Induction chemotherapy followed by right pneumonectomy for nonsmall-cell lung cancer can have a high mortality, as high as 24% in some series [9, 10]. The mortality seems to be related to an increased risk of acute lung injury. Interestingly, right pneumonectomy for MPM after induction chemotherapy may not carry the same risk of acute lung injury. Although Stewart and associates [3] reported a higher rate of acute lung injury after induction therapy for MPM, in our experience and in that reported by Opitz and colleagues [4], in only 1 patient in each series did acute lung injury develop postoperatively. The lower risk of acute lung injury after EPP for MPM could be related to the decreased function of the diseased lung with progressive shift of the mediastinum to the diseased side and redistribution of blood flow to the contralateral lung during the months before the pneumonectomy. Hence, patients undergoing pneumonectomy for MPM may already be partially "pneumonectomized," and the surgery could cause less physiologic stress on the heart and contralateral lung.

The rate of RBC transfusions for EPP has not been reported previously. We observed that only about 12% of our patients could undergo EPP without RBC transfusions and that the median number of RBC transfused was 4 units in our series. Patients undergoing induction chemotherapy had significantly lower preoperative hemoglobin and required significantly more units of RBC transfusion at the time of surgery.

Transfusion of more than 4 units of RBC was a risk factor for major postoperative complications. Interestingly, a similar observation has been reported for cardiac surgery in our institution [11, 12]. Transfusion of 5 units of RBC or more was associated with an eightfold increase in the odds of death after cardiac surgery despite adjusting for multiple potential confounding variables [11, 12]. Several studies have demonstrated an association between allogeneic RBC transfusion and increased morbidity and mortality after major pulmonary resections [13, 14]. Although it remains questionable whether RBC transfusion has a direct causative impact on postoperative complications, a large volume of RBC transfusion has been demonstrated to cause marked physiologic perturbations that can result in organ dysfunction and transfusion-related acute lung injury.

Stewart and coworkers [3] reported that they routinely administer aprotinin for EPP to reduce blood loss. Antifibrinolytic agents such as aprotinin or tranexamic acid should only be useful if there is excessive fibrinolysis at the time of surgery or thereafter. We prospectively assessed the degree of fibrinolysis in the last 6 patients reported in this series. Thromboelastography was performed before surgery, at the end of surgery, and at 24 hours after surgery with the hope to demonstrate the presence of fibrinolysis to support the use of antifibrinolytic therapy for EPP. Thromboelastography has been extensively used to guide therapy for coagulation disorders in cardiac surgery and is one of the most sensitive methods for detecting perioperative fibrinolysis [15, 16]. Interestingly, the thromboelastography coagulation index remained within normal range at the end of the surgery and at 24 hours postoperatively in each of our patients (data not shown). As no significant alteration in fibrinolysis was detected at any time point, we currently do not recommend the routine administration of antifibrinolytic in patients undergoing EPP in our institution. Aprotinin could potentially increase the risk of renal dysfunction, thrombosis, and other complications without providing any advantages to reduce the risk of bleeding [17].

The use of recombinant human erythropoietin to correct preoperatively any chemotherapy-induced anemia may be another strategy to minimize the risk of RBC transfusion at the time of surgery. This option was recently questioned, however, because of the potential increased risk of thrombotic events in patients with malignancy when the hemoglobin is raised above 120 g/L [18, 19]. We therefore would not recommend using it routinely until further studies are performed to determine its efficacy and safety before EPP in patients with MPM.

The potential impact of perioperative RBC transfusion on long-term outcome requires further evaluation. Numerous studies have looked at the impact of RBC transfusion on outcome after surgery for stage I nonsmall-cell lung cancer, and the results have remained conflicting. Several authors found that transfusion was a significant independent predictor of earlier recurrence and cancer-related death, whereas others did not [13, 20]. It remains unclear, however, whether RBC transfusion could be an indirect prognostic marker, whereas the true prognostic marker is anemia, as suggested by recent studies [21, 22]. Allogeneic blood transfusion can also impair the immune system and lead to increased risk of tumor recurrence [23]. This mechanism may be particularly important in MPM, as a strong immune reaction appears to be associated with better outcome [24].

In conclusion, EPP can be performed with a relatively low operative mortality. However, the morbidity remains high. Risk factors for major postoperative complications are right-sided EPP and transfusion of more than 4 units of allogeneic RBC. Induction chemotherapy was associated with an increased rate of RBC transfusion but did not increase the risk of major postoperative complications in our experience.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Robinson BWS, Lake RA. Advances in malignant mesothelioma N Engl J Med 2005;353:1591-1603.[Free Full Text]
  2. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, anad management of complications after 328 consecutive extrapleural pneumonectomies J Thorac Cardiovasc Surg 2004;128:138-146.[Abstract/Free Full Text]
  3. Stewart DJ, Martin-Ucar AE, Edwards JG, West K, Waller DA. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risk of induction chemotherapy, right-sided procedures and prolonged operations Eur J Cardiothorac Surg 2005;27:373-378.[Abstract/Free Full Text]
  4. Opitz I, Kestenholz P, Lardinois D, et al. Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma Eur J Cardiothorac Surg 2006;29:579-584.[Abstract/Free Full Text]
  5. de Perrot M, Uy K, Anraku M, et al. Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma J Thorac Cardiovasc Surg 2007;133:111-116.[Abstract/Free Full Text]
  6. Flores RM, Krug LM, Rosenzweig KE, et al. Induction chemotherapy, extrapleural pneumonectomy, and postoperative high-dose radiotherapy for locally advanced malignant pleural mesothelioma: a phase II trial J Thorac Oncol 2006;1:289-295.[Medline]
  7. Weder W, Kestenholz P, Taverna C, et al. Neoadjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma J Clin Oncol 2004;22:3451-3457.[Abstract/Free Full Text]
  8. International Mesothelioma Interest Group A proposed new international TNM staging system for malignant pleural mesothelioma Chest 1995;108:1122-1128.[Medline]
  9. Martin J, Ginsberg RJ, Abolhoda A, et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy Ann Thorac Surg 2001;72:1149-1154.[Abstract/Free Full Text]
  10. Darling GE, Abdurahman A, Yi QL, et al. Risk of a right pneumonectomy: role of bronchopleural fistula Ann Thorac Surg 2005;79:433-437.[Abstract/Free Full Text]
  11. Karkouti K, O’Farrell R, Yau TM, Beattie WS. Prediction of massive blood transfusion in cardiac surgery Can J Anesth 2006;53:781-794.[Medline]
  12. Karkouti K, Wijeysundera DN, Yau TM, et al. The independent association of massive blood loss with mortality in cardiac surgery Transfusion 2004;44:1453-1462.[Medline]
  13. Thomas P, Michelet P, Barlesi F, et al. Impact of blood transfusions on outcome after pneumonectomy for thoracic malignancies Eur Respir J 2007;29:565-570.[Abstract/Free Full Text]
  14. Harpole DH, DeCamp MM, Daley J, Hur K, Oprian CA, Khuri SF. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection J Thorac Cardiovasc Surg 1999;117:969-979.[Abstract/Free Full Text]
  15. Spiess BD, Tuman KJ, McCarthy RJ, DeLaria GA, Schillo R, Ivanovich AD. Thromboelastography as an indicator of post-cardiopulmonary bypass coagulopathies J Clin Monit 1987;3:25-30.[Medline]
  16. Kurata M, Horii I. Blood coagulation tests in toxicological studies—review of methods and their significance for drug safety assessment J Toxicol Sci 2004;29:13-32.[Medline]
  17. Mangano DT, Tudor IC, Dietzel C. The risk associated with aprotinin in cardiac surgery N Engl J Med 2006;354:353-365.[Abstract/Free Full Text]
  18. Wright JR, Ung YC, Julian JA, et al. Randomized, double-blind, placebo-controlled trial of erythropoietin in non-small-cell lung cancer with disease-related anemia J Clin Oncol 2007;25:1027-1032.[Abstract/Free Full Text]
  19. Steinbrook R. Erythropoietin, the FDA, and oncology N Engl J Med 2007;356:2448-2451.[Free Full Text]
  20. Nosotti M, Rebulla P, Riccardi D, et al. Correlation between perioperative blood transfusion and prognosis of patients subjected to surgery for stage I lung cancer Chest 2003;124:102-107.[Medline]
  21. Yovino S, Kwok Y, Krasna M, Bangalore M, Suntharalingam M. An association between preoperative anemia and decreased survival in early-stage non-small-cell lung cancer patients treated with surgery alone Int J Radiat Oncol Biol Phys 2005;62:1438-1443.[Medline]
  22. Berardi R, Brunelli A, Tamburrano T, et al. Perioperative anemia and blood transfusions as prognostic factors in patients undergoing resection for non-small cell lung cancers Lung Cancer 2005;49:371-376.[Medline]
  23. Ottonello L, Ghio M, Contini P, et al. Nonleukoreduced red blood cell transfusion induces a sustained inhibition of neutrophil chemotaxis by stimulating in vivo production of transforming growth factor-beta1 by neutrophils: role of the immunoglobulinlike transcript 1, sFasL, and sHLA-I Transfusion 2007;47:1395-1404.[Medline]
  24. Anraku M, Cunningham KS, Yun Z, et al. Impact of tumor-infiltrating T cells on survival in patients with malignant pleural mesothelioma. J Thorac Cardiovasc Surg. In press.



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
D. S. Trousse, J.-P. Avaro, X. B. D'Journo, C. Doddoli, P. Astoul, R. Giudicelli, P. A. Fuentes, and P. A. Thomas
Is malignant pleural mesothelioma a surgical disease? A review of 83 consecutive extra-pleural pneumonectomies
Eur. J. Cardiothorac. Surg., October 1, 2009; 36(4): 759 - 763.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
T. D. Yan, M. Boyer, M. M. Tin, D. Wong, C. Kennedy, J. McLean, P. G. Bannon, and B. C. McCaughan
Extrapleural pneumonectomy for malignant pleural mesothelioma: Outcomes of treatment and prognostic factors
J. Thorac. Cardiovasc. Surg., September 1, 2009; 138(3): 619 - 624.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Marc de Perrot
Masaki Anraku
Thomas K. Waddell
Andrew F. Pierre
Gail Darling
Shaf Keshavjee
Michael R. Johnston
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by de Perrot, M.
Right arrow Articles by Johnston, M. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by de Perrot, M.
Right arrow Articles by Johnston, M. R.
Related Collections
Right arrow Pleura

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS