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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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slide1

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

slide17

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 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%

conclusions
Conclusions
  • Malignant fibrous tumors : recurrence
  • Malignant pleural effusions
    • metastatic
    • primitive
  • Diffuse malignant mesothelioma
  • SURGERY * multimodality trials

Videothoracoscopy

slide50

Les Hôpitaux

Universitaires

de STRASBOURG

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