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Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 445, Houston, TX 77030-4009
(Email: drice{at}mdanderson.org).
The role of cytoreductive surgery in the management of malignant pleural mesothelioma remains controversial. It is generally regarded that there may be a survival benefit to complete macroscopic removal of tumor in highly selected patients. Extrapleural pneumonectomy (EPP) provides a more complete cytoreduction that pleurectomy and decortication, as evidenced by lower rates of local recurrence, and allows for the administration of adjuvant hemithoracic radiotherapy. Nevertheless, EPP does not appear to have a survival advantage over pleurectomy and decortication [1]. Despite improved local control with EPP, most patients recur with metastases to the contralateral thorax or abdominal cavity. In the study by Politi and Borzellino [2], tumor recurrence developed in 53 of 57 patients (93%) after EPP, which highlights the inadequacy of our current surgical treatment strategies.
Treatment options for patients with recurrent mesothelioma after EPP are generally limited. Most patients who recur have distant metastases and require systemic treatment. Rates of local recurrence vary between 13% and 30%; however, purely isolated local recurrence is rare. Many patients who recur have previously undergone radiotherapy, which further limits treatment options.
Data are lacking in the literature on the management of these patients, and therefore Politi and Borzellino's findings are of interest, despite the small sample size. Several findings are worth commenting on: First, 3 of 8 of the recurrences that were operated on occurred in the retrocrural region, an area that can be difficult to adequately treat with conventional adjuvant radiotherapy, particularly if the diaphragmatic reconstruction is not placed low enough. The use of intensity-modulated radiation provides better dose distribution in this area compared with conventional 3-dimensional conformal radiation and may improve local control in this region after EPP.
Second, the importance of positron emission tomography (PET) in the initial staging of mesothelioma is well documented, and Politi and Borzellino suggest that it is also useful for defining the true extent of recurrent disease. Certainly, it would seem rational to perform PET before any attempt to resect a putative local recurrence.
Third, although Politi and Borzellino conclude that the observed overall median survival of 14.5 months argues against performing repeat resection for curative purposes, survival of patients who underwent chest wall resection ranged from 14 to 29 months. In a group of patients in which many will have already undergone prior chemotherapy and radiotherapy and therefore have limited nonsurgical options, this survival would appear to be better than expected.
Mesothelioma remains a disease that is recalcitrant to current surgical and nonsurgical modalities. Nevertheless, aggressive cytoreductive multimodality approaches appear to result in prolonged survival in highly selected patients. In a very small subset of these patients in whom an isolated local recurrence develops after EPP, Politi and Borzellino have shown that repeat resection can be occasionally performed and that it can be done safely, and they have at least provided us an option to consider, particularly in cases where radiotherapy would not be feasible.
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