Multimodality Therapy Including Pleurectomy/Decortication in Pleural Mesothelioma: Long-term Outcomes in 152 Consecutive Patients: A Retrospective Cohort Study.

Objective: To evaluate the long-term outcomes of pleurectomy decortication, systemic chemotherapy, and prophylactic radiotherapy in pleural mesothelioma (PM).

Background: There is no known cure for PM and cytoreductive surgery remains controversial.

Methods: Retrospective analysis of a cohort of patients treated consecutively between October 2004 and October 2019. Patients with PM were referred to our clinic and those with favorable prognostic factors and with completely resectable disease were selected for trimodality therapy. Our treatment protocol involved total pleurectomy decortication (P/D) and hyperthermic intrapleural povidone-iodine, prophylactic chest wall radiotherapy, and systemic chemotherapy. 18 FDG-PET-CT was used routinely to diagnose disease recurrence. Further systemic therapies were administered when appropriate. Survival and prognostic factors were analyzed using the Kaplan-Meier method and univariate and multivariate Cox regressions.

Results: A total of 152 consecutive patients had P/D performed with curative intent. The median age was 64 years, and the male/female ratio was 123/29. Thirty-one patients (20.4%) had received chemotherapy preoperatively. Thirty-five patients (23%) underwent extended resections. Sixty-four patients (42%) suffered a postoperative complication, but 90-day mortality was nil. Histologic types were epithelioid in 107 patients (70.4%) and non-epithelioid in 45 (29.6%). Pathologic stages were: I: 88, II: 0, III: 63, and IV: 1 (eighth TNM classification). Six patients (4%) did not receive systemic chemotherapy, and 3 (2%) no radiotherapy postoperatively. Seventy-four patients (48.7%) received further systemic therapies for relapse. Median overall survival was 31.7 months, 35.0 months for epithelioid, and 18.3 months for non-epithelioid histology. Histologic type was the only predictor of overall survival, independent of resection status, pathologic stage, or lymph node status, on multivariate analysis.

Conclusions: P/D is a safe and well-tolerated procedure resulting in no mortality and acceptable morbidity. Most patients can receive radiotherapy and systemic chemotherapy in due time and receive further therapies on relapse, resulting in prolonged survival mainly in those with early-stage epithelioid mesothelioma.