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Les Hôpitaux Universitaires de STRASBOURG

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

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  1. Les Hôpitaux Universitaires de STRASBOURG

  2. SurgicalTreatment of Malignant Pleural Diseases Prof. J.M. Wihlm Department of Thoracic Surgery Université Louis Pasteur Strasbourg, France

  3. Presentation • Malignant fibrous tumors • fibroma, fibrosarcoma • Malignant pleural effusions • metastatic • primitive • Diffuse malignant mesothelioma

  4. Malignant fibrous tumors • Pathologic features • Macroscopic • large • atypical location • necrosis and hemorrhage • Microscopic •  cellularity, pleomorphism, high mitotic index • immunohistochemically: B=M

  5. Malignant fibrous tumors • Clinic • pain, cough, dyspnea, fever • hypoglycemia (11%) (3% for benign) • Radiology • non-specific • pleural effusion (32%) • rib erosion

  6. Malignant fibrous tumors • Diagnosis • histologic examination • chest wall invasion • recurrence • Prognosis • survival : 12% - 45% • recurrence +++ local, intrapleural, metastasis • Complete resection

  7. Malignant fibrous tumors • Surgical treatment • large local excision + • pulmonary pedicule • parietal pleural pedicule • chest wall • Postoperative therapy : • incomplete resection • radiotherapy : titanium clips • chemotherapy

  8. 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

  9. Malignant pleural effusions • Clinic • dyspnea (exertion), pain, weight loss • no symptom : • chest Xray finding • physical examination • Radiology • pleural effusion • ipsilateral, bilateral

  10. 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

  11. Videothoracoscopy Axillary approach  Conversion thoracotomy

  12. videothoracoscopy : intrapleural loculations

  13. 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 »

  14. Malignant pleural effusions • Decision • general condition • symptoms • expected survival

  15. Malignant pleural effusions • Treatment • Periodical thoracentesis • Chest tube  « talc slurry » • Thoracoscopy : pleurodesis • talc poudrage • abrasion • pleurectomy • Thoracotomy + pleurectomy (decortication)

  16. Malignant pleural effusions • Treatment : Chest tube (variety) Ambulatory technique

  17. Malignant pleural effusions • Treatment • Periodical thoracentesis • Chest tube  « talc slurry » • Thoracoscopy : pleurodesis • talc poudrage • abrasion • pleurectomy • Thoracotomy + pleurectomy (decortication) Pericardial window

  18. Videothoracoscopic pericardial window

  19. 6 month postop control

  20. 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

  21. 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

  22. 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

  23. 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

  24. Diffuse malignant mesotheliomaCT scan imaging

  25. Diffuse malignant mesotheliomaCT scan imaging

  26. Diffuse malignant mesotheliomaCT scan imaging

  27. Diffuse malignant mesotheliomaPET scan imaging

  28. Diffuse malignant mesotheliomaTreatment options • Surgery • Radiation • Chemotherapy • Immunotherapy • Supportive care • Combined modalities

  29. 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 ?

  30. Diffuse malignant mesotheliomaChemotherapy • Phase II studies +++ •  all drugs • Response rate : 20% (30-40%) • Problem : inclusion criteria • « remain disappointing » Future : 

  31. 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

  32. Diffuse malignant mesotheliomaImmunotherapy Interferon-alpha 2a : systemic Interferon-gamma : intrapleural

  33. Diffuse malignant mesotheliomaTreatment options • Surgery • Radiation • Chemotherapy • Immunotherapy • Supportive care • Combined modalities

  34. Diffuse malignant mesotheliomaSurgical treatment (1) : palliative • Thoracoscopy (video) • pleural biopsies • palliative treatment : Talc poudrage • Limited pleurectomy • Parietal pleura pleurodesis

  35. 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

  36. 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

  37. Pleurectomy-decortication

  38. Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique

  39. Diffuse malignant mesotheliomaExtrapleural pneumonectomy : technique

  40. Diffuse malignant mesotheliomaExtrapleural pneumonectomy : mortality

  41. 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%

  42. Diffuse malignant mesotheliomaMultimodality treatment

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

  44. Les Hôpitaux Universitaires de STRASBOURG

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