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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 h pitaux universitaires de strasbourg

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


Les h pitaux universitaires de strasbourg

Videothoracoscopy

Axillary approach 

Conversion thoracotomy


Les h pitaux universitaires de strasbourg

videothoracoscopy : intrapleural loculations


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


    Videothoracoscopic pericardial window

    Videothoracoscopic pericardial window


    Les h pitaux universitaires de strasbourg

    6 month postop control


    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 ct scan imaging

    Diffuse malignant mesotheliomaCT scan imaging


    Diffuse malignant mesothelioma ct scan imaging1

    Diffuse malignant mesotheliomaCT scan imaging


    Diffuse malignant mesothelioma ct scan imaging2

    Diffuse malignant mesotheliomaCT scan imaging


    Diffuse malignant mesothelioma pet scan imaging

    Diffuse malignant mesotheliomaPET scan imaging


    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


    Pleurectomy decortication

    Pleurectomy-decortication


    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 h pitaux universitaires de strasbourg

    Les Hôpitaux

    Universitaires

    de STRASBOURG


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