|
|
|
Eric Vallières MD, , Karen Hunt MD, Keith Stelzer MD.
Introduction:
Extrapleural pneumonectomy (EPP) remains the most effective therapeutic
modality to locally control DMM but both local and systemic recurrences
are common. Effective induction chemotherapy and adjuvant neutron radiation
therapy could potentially improve both local and systemic control and
impact survival. This phase II trial evaluates the feasibility of induction
cisplatin, methotrexate and vinblastine chemotherapy (PMV), EPP and adjuvant
fast neutron radiotherapy (FNRT) in the treatment of DMM.
Methods:
Patients with clinical stages I-III DMM, Karnofsky 80% or better and who
have adequate cardiopulmonary reserves were given induction PMV followed
by EPP and adjuvant whole hemithorax FNRT. Data was collected prospectively.
Results:
Twenty-three patients (19 M, 4F), ages 38 to 74, clinical IMIG stages
I (10), II(6) and III (7) have initiated this protocol. This represents
62 % of all the patients evaluated during the same period in our Mesothelioma
Multidisciplinary Clinic. Fourteen of these patients are completing their
induction PMV. In the other 9, a clinical response to chemotherapy was
seen in 7 patients, a radiological response in 5. All 9 patients have
undergone EPP ( 6 right, 3 left). Gross positive margins were present
in 3 patients, microscopic positive margins were identified in another
5. The only complete resection was in a patient with prechemotherapy sarcomatous
histology who was NED at surgery. Histology was epithelial in 6, mixed
or desmoplastic in 2 and sarcomatous in 1. The IMIG pathological stage
distribution was: CR (1), stage III (5) and stage IV(3). There was no
operative mortality and hospital stays ranged from 6 to 11 days. Delayed
morbidity was major in 3 patients. Seven patients have completed the adjuvant
FNRT, one patient received conventional RT and one patient was diagnosed
with brain metastases 6 weeks after resection. Three patients have died,
2 of their DMM, both had biphasic histology, N2 disease at resection and
neither had demonstrated a radiological response after PMV. The 6 remaining
patients are alive at 35,29,17,16, 14 and 12 months post diagnosis. Five
of the survivors have recurred (local 1, regional 1, systemic 3).
Conclusion: Induction PMV, EPP and FNRT appears
safe in this early experience and provides excellent local control, even
in higher T stage disease. Regional and systemic recurrences are however
a problem. The survival of these high stage patients may be improved,
longer follow-up and a larger experience are required.
Related: Patient selection criteria for extrapleural pneumonectomy