Les Hôpitaux
Download
1 / 50

Les Hôpitaux Universitaires de STRASBOURG - PowerPoint PPT Presentation


  • 140 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Les Hôpitaux Universitaires de STRASBOURG' - isanne


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Les Hôpitaux

Universitaires

de STRASBOURG


Surgical treatment of malignant pleural diseases

SurgicalTreatment of Malignant Pleural Diseases

Prof. J.M. Wihlm

Department of Thoracic Surgery

Université Louis Pasteur

Strasbourg, France


Presentation
Presentation

  • Malignant fibrous tumors

    • fibroma, fibrosarcoma

  • Malignant pleural effusions

    • metastatic

    • primitive

  • Diffuse malignant mesothelioma


Malignant fibrous tumors
Malignant fibrous tumors

  • Pathologic features

    • Macroscopic

      • large

      • atypical location

      • necrosis and hemorrhage

    • Microscopic

      •  cellularity, pleomorphism, high mitotic index

      • immunohistochemically: B=M


Malignant fibrous tumors1
Malignant fibrous tumors

  • Clinic

    • pain, cough, dyspnea, fever

    • hypoglycemia (11%) (3% for benign)

  • Radiology

    • non-specific

    • pleural effusion (32%)

    • rib erosion


Malignant fibrous tumors2
Malignant fibrous tumors

  • Diagnosis

    • histologic examination

    • chest wall invasion

    • recurrence

  • Prognosis

    • survival : 12% - 45%

    • recurrence +++ local, intrapleural, metastasis

    • Complete resection


Malignant fibrous tumors3
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
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 effusions1
Malignant pleural effusions

  • Clinic

    • dyspnea (exertion), pain, weight loss

    • no symptom :

      • chest Xray finding

      • physical examination

  • Radiology

    • pleural effusion

    • ipsilateral, bilateral


Malignant pleural effusions2
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 effusions3
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 effusions4
    Malignant pleural effusions

    • Decision

      • general condition

      • symptoms

      • expected survival


    Malignant pleural effusions5
    Malignant pleural effusions

    • Treatment

      • Periodical thoracentesis

      • Chest tube  « talc slurry »

      • Thoracoscopy : pleurodesis

        • talc poudrage

        • abrasion

        • pleurectomy

      • Thoracotomy + pleurectomy (decortication)


    Malignant pleural effusions6
    Malignant pleural effusions

    • Treatment :

      Chest tube

      (variety)

      Ambulatory

      technique


    Malignant pleural effusions7
    Malignant pleural effusions

    • Treatment

      • Periodical thoracentesis

      • Chest tube  « talc slurry »

      • Thoracoscopy : pleurodesis

        • talc poudrage

        • abrasion

        • pleurectomy

      • Thoracotomy + pleurectomy (decortication)

    Pericardial window




    Malignant pleural effusions indications for pleurectomy

    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

    • « 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 mesothelioma evaluation before treatment
    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 mesothelioma evaluation before treatment1
    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 mesothelioma treatment options
    Diffuse malignant mesotheliomaTreatment options

    • Surgery

    • Radiation

    • Chemotherapy

    • Immunotherapy

    • Supportive care

    • Combined modalities


    Diffuse malignant mesothelioma radiation therapy
    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 mesothelioma chemotherapy
    Diffuse malignant mesotheliomaChemotherapy

    • Phase II studies +++

    •  all drugs

    • Response rate : 20% (30-40%)

    • Problem : inclusion criteria

    • « remain disappointing »

    Future : 


    Diffuse malignant mesothelioma chemotherapy new drug
    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 mesothelioma immunotherapy
    Diffuse malignant mesotheliomaImmunotherapy

    Interferon-alpha 2a : systemic

    Interferon-gamma : intrapleural


    Diffuse malignant mesothelioma treatment options1
    Diffuse malignant mesotheliomaTreatment options

    • Surgery

    • Radiation

    • Chemotherapy

    • Immunotherapy

    • Supportive care

    • Combined modalities


    Diffuse malignant mesothelioma surgical treatment 1 palliative
    Diffuse malignant mesotheliomaSurgical treatment (1) : palliative

    • Thoracoscopy (video)

      • pleural biopsies

      • palliative treatment :

        Talc poudrage

    • Limited pleurectomy

      • Parietal pleura

    pleurodesis


    Diffuse malignant mesothelioma surgical treatment 2 resection
    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


    Diffuse malignant mesothelioma surgical treatment 2 resection1

    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 mesothelioma extrapleural pneumonectomy technique
    Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique


    Diffuse malignant mesothelioma extrapleural pneumonectomy technique1
    Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique


    Diffuse malignant mesothelioma extrapleural pneumonectomy mortality
    Diffuse malignant mesotheliomaExtrapleural pneumonectomy : mortality


    Diffuse malignant mesothelioma extrapleural pneumonectomy results
    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%


    Diffuse malignant mesothelioma multimodality treatment
    Diffuse malignant mesotheliomaMultimodality treatment


    Conclusions
    Conclusions

    • Malignant fibrous tumors : recurrence

    • Malignant pleural effusions

      • metastatic

      • primitive

    • Diffuse malignant mesothelioma

    • SURGERY * multimodality trials

    Videothoracoscopy


    Les Hôpitaux

    Universitaires

    de STRASBOURG


    ad