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Les Hôpitaux Universitaires de STRASBOURG. Surgical Treatment of Malignant Pleural Diseases. Prof. J.M. Wihlm Department of Thoracic Surgery Université Louis Pasteur Strasbourg, France. Presentation. Malignant fibrous tumors fibroma, fibrosarcoma Malignant pleural effusions
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Les Hôpitaux Universitaires de STRASBOURG
SurgicalTreatment of Malignant Pleural Diseases Prof. J.M. Wihlm Department of Thoracic Surgery Université Louis Pasteur Strasbourg, France
Presentation • Malignant fibrous tumors • fibroma, fibrosarcoma • Malignant pleural effusions • metastatic • primitive • Diffuse malignant mesothelioma
Malignant fibrous tumors • Pathologic features • Macroscopic • large • atypical location • necrosis and hemorrhage • Microscopic • cellularity, pleomorphism, high mitotic index • immunohistochemically: B=M
Malignant fibrous tumors • Clinic • pain, cough, dyspnea, fever • hypoglycemia (11%) (3% for benign) • Radiology • non-specific • pleural effusion (32%) • rib erosion
Malignant fibrous tumors • Diagnosis • histologic examination • chest wall invasion • recurrence • Prognosis • survival : 12% - 45% • recurrence +++ local, intrapleural, metastasis • Complete resection
Malignant fibrous tumors • Surgical treatment • large local excision + • pulmonary pedicule • parietal pleural pedicule • chest wall • Postoperative therapy : • incomplete resection • radiotherapy : titanium clips • chemotherapy
Malignant pleural effusions • Metastatic «Virtually all cancers metastasize to the pleura»* • lung cancer • breast cancer • lymphoma, Hodgkin’s • melanoma • Primitive : Mesothelioma * S.A. Sahn, General Thoracic Surgery, Thomas W. Shields
Malignant pleural effusions • Clinic • dyspnea (exertion), pain, weight loss • no symptom : • chest Xray finding • physical examination • Radiology • pleural effusion • ipsilateral, bilateral
Malignant pleural effusions • Diagnosis • pleural fluid : serous bloody, exsudate • cytology : 66% • percutaneous pleural biospy : 46% • thoracoscopy * : 95% • videothoracoscopy : 97% • (exploratory thoracotomy) : 73% parietal seeding * C. Boutin, R. Lodenkemper, Eur Respir J, 1993
Videothoracoscopy Axillary approach Conversion thoracotomy
Malignant pleural effusions • Prognosis : poor • few months : lung, digestive, ovary • few years : breast • intermediate : lymphomas • Palliative treatment • short, efficient • SURGERY • Problem of stage IV lung cancer« paramalignant »
Malignant pleural effusions • Decision • general condition • symptoms • expected survival
Malignant pleural effusions • Treatment • Periodical thoracentesis • Chest tube « talc slurry » • Thoracoscopy : pleurodesis • talc poudrage • abrasion • pleurectomy • Thoracotomy + pleurectomy (decortication)
Malignant pleural effusions • Treatment : Chest tube (variety) Ambulatory technique
Malignant pleural effusions • Treatment • Periodical thoracentesis • Chest tube « talc slurry » • Thoracoscopy : pleurodesis • talc poudrage • abrasion • pleurectomy • Thoracotomy + pleurectomy (decortication) Pericardial window
Cons major surgical procedure morbidity (23%) mortality (10-18%) Indications survival 6 months good condition trapped lung (CT scan) failed pleurodesis Diagnostic thoracotomy Malignant pleural effusionsIndications for pleurectomy Selected patients
Diffuse malignant mesothelioma • « diffuse malignant mesothelioma is an uncommon and lethal cancer for which there is currently no standard treatment »* • « its biological dehaviour remains an enigma, and the treatment of this cancer is still controversial »* * Valerie W. Rusch, Cornell University, New York
Diffuse malignant mesotheliomaEvaluation before treatment • Staging system : • Butchard (1976) • Dimitrov and McMahon (1987) • UICC (1990) : TNM based • Rusch (1995) : new international TNM International Mesothelioma Interest Group • type of disease progression • correlation TNM status survival • outcome & clinical trial analyses
Diffuse malignant mesotheliomaEvaluation before treatment • Imaging • Chest Xray • CT scan, MRI • PET scan • Video-thoracoscopy • Mediastinoscopy • Laparoscopy 49% distant metastasis at autopsy Ruffie R, J Clin Oncology, 1989
Diffuse malignant mesotheliomaTreatment options • Surgery • Radiation • Chemotherapy • Immunotherapy • Supportive care • Combined modalities
Diffuse malignant mesotheliomaRadiation therapy • Alone ? • Associated with surgery chemotherapy • Local symptom control (45 Gy) • Volume : hemithorax, vital structures • Adjuvant therapy after tumor reduction • Prevention of parietal tumor implants after thoracoscopy Future : high-dose ?
Diffuse malignant mesotheliomaChemotherapy • Phase II studies +++ • all drugs • Response rate : 20% (30-40%) • Problem : inclusion criteria • « remain disappointing » Future :
Diffuse malignant mesotheliomaChemotherapy : new drug • Pemetrexed in combination with cisplatin is the only treatment with activity proven in phase III trials. It is the first, and only registered chemotherapy for the treatment of malignant Mesothelioma.Pemetrexed not only improves survival and response rate but also palliates symptoms and improves quality of life and lung function. 41% response rate Nicholas J. Voglelzangl, Nevada Cancer Institute, Las Vegas
Diffuse malignant mesotheliomaImmunotherapy Interferon-alpha 2a : systemic Interferon-gamma : intrapleural
Diffuse malignant mesotheliomaTreatment options • Surgery • Radiation • Chemotherapy • Immunotherapy • Supportive care • Combined modalities
Diffuse malignant mesotheliomaSurgical treatment (1) : palliative • Thoracoscopy (video) • pleural biopsies • palliative treatment : Talc poudrage • Limited pleurectomy • Parietal pleura pleurodesis
Diffuse malignant mesotheliomaSurgical treatment (2) : resection • Pleurectomy-decortication • Extrapleural pneumonectomy (pleuro-pneumonectomy) * Valerie W. Rusch, Cornell University, New York * David J. Sugarbaker, Harvard Medical School, Boston
Pleurectomy-decortication parietal pleura visceral pleura hemidiaphragm pericardium Extrapleural pneumonectomy En bloc : lung parietal pleura visceral pleura hemidiaphragm pericardium Diffuse malignant mesotheliomaSurgical treatment (2) : resection
Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique
Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique
Diffuse malignant mesotheliomaExtrapleural pneumonectomy : mortality
Diffuse malignant mesotheliomaExtrapleural pneumonectomy : results • Mortality : 3,8% (Pneumonectomy : 5-10%) • Factors of improvement • Patient selection • Preoperative preparation • Intraoperative management • Postoperative care (PCEA, epidural analgesia) • Cell type : epithelial > sarcomatous cell • Surgical resection margins • Localized lymph nodes • Post-op chemo + radiation therapy 31 pts : 2-year survival : 68% 5-year survival : 46%
Conclusions • Malignant fibrous tumors : recurrence • Malignant pleural effusions • metastatic • primitive • Diffuse malignant mesothelioma • SURGERY * multimodality trials Videothoracoscopy
Les Hôpitaux Universitaires de STRASBOURG