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Thoracic Cancer Sep 2023Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT),...
BACKGROUND
Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience.
METHODS
This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups.
RESULTS
Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively.
DISCUSSION
Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.
Topics: Humans; Aged; Mesothelioma, Malignant; Mesothelioma; Pleural Neoplasms; Lung Neoplasms; Treatment Outcome; Morbidity; Sepsis
PubMed: 37574596
DOI: 10.1111/1759-7714.15067 -
Journal of Clinical Medicine Sep 2022Objective: Malignant pleural mesothelioma (MPM) is a rare and aggressive malignant cancer for which there are poor treatment options. Extrapleural pneumonectomy (EPP)... (Review)
Review
Objective: Malignant pleural mesothelioma (MPM) is a rare and aggressive malignant cancer for which there are poor treatment options. Extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) are the two most used surgical procedures in patients with resectable disease. We reviewed the available literature in order to compare the overall survival and postoperative complications of EPP and P/D and to provide evidence for the best procedure in the treatment of MPM. Methods: We performed a systematic review of the literature, including studies from August 2018 to May 2022. The primary outcome was 5-year overall survival (OS) and the secondary outcomes were 30-day mortality, 90-day mortality and peri-operative complications. Results: Thirteen studies were considered, including a total of 1624 patients treated with EPP and 2147 treated with P/D. The estimated pooled HR showed a significant lower hazard for P/D compared to EPP in terms of OS (HR = 0.76; 95% CI from 0.62 to 0.94; p < 0.001). In 12 studies, the risk for 30-day mortality was lower for patients treated with P/D (RR = 0.49; 95% CI from 0.31 to 0.76; p = <0.01), whereas only five studies reported 90-day mortality, and no statistically significant difference between EPP and P/D was found (RR = 0.71; 95% CI from 0.47 to 1.07; p = 0.10). The OS restricted mean survival time difference meta-analysis (RMSDT) confirms the superior survival of P/D on the EPP, a superiority that increases from 0.54 months at one year to 4.23 at five years. The incidence of postoperative empyema, atrial fibrillation, bleeding and bronchopleural fistula was significantly increased in the EPP group except for prolonged air leakage, which is only characteristic of P/D. Conclusions: Using two different statistical methods, this meta-analysis suggests that long-term survival after surgical treatment for resectable MPM is greater for patients undergoing P/D. Long-term survival had never been previously analyzed with appropriate tests; on the contrary, our result is consistent with the previous meta-analyses and reinforces the evidence of lower 30-day mortality and the prevalence of postoperative complications in P/D versus EPP patients. The recent introduction of innovative therapeutic schemes, both adjuvant and neoadjuvant therapy, keeps the discussion on surgical strategy open and will require new studies.
PubMed: 36233416
DOI: 10.3390/jcm11195544 -
Interactive Cardiovascular and Thoracic... Oct 2022Although the diagnosis of malignant pleural mesothelioma at an in situ stage was traditionally challenging, it is now possible owing to advances in molecular biological...
Although the diagnosis of malignant pleural mesothelioma at an in situ stage was traditionally challenging, it is now possible owing to advances in molecular biological methods such as P16 fluorescence in situ hybridization or BRCA1-associated protein 1 immunohistochemistry. Here, we report the first case, to our knowledge, of total parietal pleurectomy for mesothelioma in situ. Future follow-up and accumulation of cases are necessary to determine whether total parietal pleurectomy could be applied as a treatment for mesothelioma in situ or not.
Topics: Humans; Mesothelioma, Malignant; Pleural Neoplasms; In Situ Hybridization, Fluorescence; Lung Neoplasms; Mesothelioma
PubMed: 36205712
DOI: 10.1093/icvts/ivac255 -
Monaldi Archives For Chest Disease =... Sep 2022Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and...
Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be "catamenial" happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.
Topics: Female; Humans; Endometriosis; Hemothorax; Hemopneumothorax; Quality of Life; Pneumothorax; Thoracic Surgery, Video-Assisted
PubMed: 36172717
DOI: 10.4081/monaldi.2022.2401 -
Journal of Clinical Medicine Jul 2020Surgical procedures for malignant pleural mesothelioma (MPM) include extrapleural pneumonectomy (EPP), extended pleurectomy/decortication (P/D) and P/D. EPP has been... (Review)
Review
BACKGROUND
Surgical procedures for malignant pleural mesothelioma (MPM) include extrapleural pneumonectomy (EPP), extended pleurectomy/decortication (P/D) and P/D. EPP has been applied to MPM for a long time, but the postoperative status is extremely poor due to the loss of one whole lung. We compared the mortality, morbidity and median survival time (MST) of lung-sparing surgery (extended P/D or P/D) and lung-sacrificing surgery (EPP) for MPM by performing a systematic review.
METHODS
We extracted the number of events and patients from the literature identified in electronic databases. Ultimately, 15 reports were selected, and 2674 MPM patients, including 1434 patients undergoing EPP and 1240 patients undergoing extended P/D or P/D, were analyzed.
RESULTS
Our systematic review showed that lung-sparing surgery was significantly superior to lung-sacrificing surgery in both the surgical-related mortality (extended P/D vs. EPP: 3.19% vs. 7.65%, < 0.01; P/D vs. EPP: 1.85% vs. 7.34%, < 0.01) and morbidity (extended P/D vs. EPP: 35.7% vs. 60.0%, < 0.01; P/D vs. EPP: 9.52% vs. 20.89%, < 0.01). Lung-sparing surgery was not inferior to EPP in terms of MST.
CONCLUSION
Although no prospective randomized controlled trial has been conducted, it may be time to change the standard surgical method for MPM from lung-sacrificing surgery to lung-sparing surgery.
PubMed: 32650433
DOI: 10.3390/jcm9072153 -
Cureus Apr 2021The group (SAG) consists of three bacteria (, , and ) that are known commensals of the upper respiratory, digestive, and reproductive tracts. While a rare occurrence,...
The group (SAG) consists of three bacteria (, , and ) that are known commensals of the upper respiratory, digestive, and reproductive tracts. While a rare occurrence, these bacteria have the capability of causing devastating pyogenic infections and ensuing abscess formations. It is often difficult to distinguish this group as a contaminant or the offending organism (as it is often cultured in respiratory specimens); therefore, it is important to understand the risk factors, clinical presentation, and diagnostic findings that can provide a more accurate picture to identify the organism. Published literature pertaining to the SAG group has rarely documented any invasive surgical intervention that was undertaken for treatment. We describe a case of a 59-year-old male who presented for persistent chest pain and profuse productive cough weeks after he was diagnosed with a left lower extremity deep vein thrombosis and right-sided pulmonary embolism. The patient was found to have a rapidly evolving right middle lobe lung abscess complicated by a right hemithorax empyema. Management included an exploration of the right chest, decortication, parietal pleurectomy, and partial excision of the right middle lobe. Subsequently, the patient completed four weeks of antibiotics with ertapenem.
PubMed: 34017651
DOI: 10.7759/cureus.14534 -
JTCVS Open Dec 2023To evaluate the efficacy of multimodality treatment including extended pleurectomy/decortication (P/D) and hyperthermic intraoperative chemotherapy (HIOC) with cisplatin...
OBJECTIVE
To evaluate the efficacy of multimodality treatment including extended pleurectomy/decortication (P/D) and hyperthermic intraoperative chemotherapy (HIOC) with cisplatin for malignant pleural mesothelioma (MPM), we investigated the pharmacokinetics of platinum, adverse events after HIOC, and survival outcome.
METHODS
Fifty-three patients with pathologically diagnosed MPM (cT1-3N0-1M0, excluding sarcomatoid) underwent an extended P/D and HIOC (cisplatin 80 mg/m in saline 2 L, 42°C, 60 minutes) since 2011. The protocol includes postoperative 4 cycles of cisplatin and pemetrexed. Platinum concentrations in the perfusate (before and after) and the serum (1, 2, 4, 8, 24, 48, 72 hours after perfusion) were measured in 10 patients. Mortality and morbidity, especially adverse events of renal function, were investigated, and survival and affecting factors were examined.
RESULTS
All patients obtained macroscopic complete resection and pathologic staging revealed as follows: T1/2/3/4: 12/8/23/10, N0/1: 36/17, stage 1A/1B-3A/3B: 12/31/10, respectively. Platinum concentrations in the perfusate indicated that 28% of the dose remained in the pleural cavity, and the maximum concentration in the serum was 0.91 μg/mL. Six patients (11%) showed elevated max-creatinine (>2 mg/dL) postoperatively. Two patients (4%) received renal-replacement therapy, and one was weaned before discharge. There was no 30-day mortality and one in-hospital death (1.9%). Forty-six patients (87%) received multiple cycles of perioperative systemic chemotherapy. Median overall survival (OS) and disease-free survival (DFS) were 52.4 months and 18.7 months. Patents with stage 1A demonstrated a 5-year OS of 67.3% and a median DFS of 67.1 months, and patients with stage 1B-3A demonstrated a 5-year OS of 50.1% and a median DFS of 20.4 months. Univariate analysis showed histological subtype, p-T, p-stage, and multimodality treatment as significant factors affecting OS. Multivariate analysis revealed histology, p-stage, and multimodality as independent.
CONCLUSIONS
Extended P/D and HIOC with cisplatin for MPM is acceptable with limited acute kidney injury. This multimodality protocol provides promising favorable survival for stage 1A-3A disease.
PubMed: 38204668
DOI: 10.1016/j.xjon.2023.09.005 -
Northern Clinics of Istanbul 2023The purpose of this study was to determine the efficacy and tolerability of hemithoracic radiotherapy implemented with helical tomotherapy (HTT) in malignant pleural...
OBJECTIVE
The purpose of this study was to determine the efficacy and tolerability of hemithoracic radiotherapy implemented with helical tomotherapy (HTT) in malignant pleural mesothelioma (MPM) patients.
METHODS
Between October 2018 and December 2020, data from 11 MPM patients who received trimodality therapy, including lung-sparing surgery (pleurectomy-decortication, P/D), adjuvant chemotherapy (cisplatin+ pemetrexed), and radiotherapy, were retrospectively reviewed. HTT was used to deliver a total of 30 Gy, 50-54 Gy or 59.4-60 Gy to R2 disease with 1.8-2 Gy daily doses. Descriptive data are presented in number (percentage) or median (minimum- maximum). The Kaplan-Meier method was used to calculate survival data. In patients with toxicities, the risk organ doses were compared using the Mann-Whitney U test.
RESULTS
The median follow-up was 20.5 (12-30) months. Two-year local control, disease-free, and overall survival rates were 48.5%, 49%, and 77.9%, respectively. The median prescribed dose for planning target volume (PTV) was 50.4±8.7 (30-60) Gy. Mean dose (D) of total lung was 19.9±6 (10.4-26) Gy; the V20 (%) of ipsilateral and contralateral lungs were 89.±11.2 (62.7-100) and 0.7±2.1 (0.49-5.9), respectively. Esophageal D and maximum doses (D) were found as 21.7±8.4 (7.4-34) and 53.1±10.4 (25.4-64.4) Gy, respectively. V30 (%) and Dmean of heart were 22.3%±13.4% (3.9-47) and 21±5.7 (10.8-29.3) Gy, respectively. D of medulla spinalis (MS) was 38.6± 1.3 (13.7-48) Gy. Grade 1-2 radiation pneumonitis (RP) developed in 4 (36.4%) and esophagitis in 2 (18.2%) patients. RP was found to be associated with MS and esophageal doses (p<0.05). Myelitis was diagnosed in 1 (9.1%) patient (MS D: 29 Gy).
CONCLUSION
HTT can be used as part of trimodality therapy for MPM patients with acceptable toxicities. MS and esophageal doses should be considered for radiation pneumonitis risk, and new dose constraints for these organs should be defined.
PubMed: 37181055
DOI: 10.14744/nci.2023.53896 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jan 2022In this study, we aimed to analyze the effects of admission time to the hospital and different variables on the treatment efficiency and to evaluate the recurrence...
BACKGROUND
In this study, we aimed to analyze the effects of admission time to the hospital and different variables on the treatment efficiency and to evaluate the recurrence during the clinical management process in patients with the diagnosis of primary spontaneous pneumothorax.
METHODS
A total of 149 patients with primary spontaneous pneumothorax (131 males, 18 females; mean age: 24.8±6.8 years; range, 17 to 35 years) treated in our clinic between January 2015 and December 2019 were retrospectively analyzed. Time from symptom onset to hospital admission (admission time) was classified as three periods: <24 h, between 24 and 72 h, and >72 h. Data including admission time, demographic and clinical characteristics, smoking history, body mass index, the use of pleurectomy or pleural abrasion during surgery were collected from the charts of the patients.
RESULTS
Admission time had no statistically significant effect on the length of hospital stay, recurrence, and the need for surgery. Male sex, smoking history, and lower body mass index had no significant effect on the recurrence. Recurrence and length of hospital stay did not significantly differ between the patients in whom pleurectomy or pleural abrasion added to the procedure during the operation.
CONCLUSION
A longer interval between symptom onset and hospital admission and lower body mass index have no adverse effect on treatment outcomes and the recurrence in patients with primary spontaneous pneumothorax. Despite the fact that surgical treatment significantly decreases the recurrence rate, pleurectomy and pleural abrasion techniques have no significant difference on the clinical influence and recurrence of these patients.
PubMed: 35444856
DOI: 10.5606/tgkdc.dergisi.2022.21242 -
World Journal of Clinical Oncology Aug 2021Malignant pleural mesothelioma (MPM) is a rare tumor with poor prognosis and rising incidence. Palliative care is common in MPM as radical treatment with curative intent... (Review)
Review
Malignant pleural mesothelioma (MPM) is a rare tumor with poor prognosis and rising incidence. Palliative care is common in MPM as radical treatment with curative intent is often not possible due to metastasis or extensive locoregional involvement. Numerous therapeutic advances have been made in recent years, including the use of less aggressive surgical techniques associated with lower morbidity and mortality (, pleurectomy/decortication), technological advancements in the field of radiotherapy (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic body radiotherapy, proton therapy), and developments in systemic therapies (chemotherapy and immunotherapy). These improvements have had as yet only a modest effect on local control and survival. Advances in the management of MPM and standardization of care are hampered by the evidence to date, limited by high heterogeneity among studies and small sample sizes. In this clinical guideline prepared by the oncological group for the study of lung cancer of the Spanish Society of Radiation Oncology, we review clinical, histologic, and therapeutic aspects of MPM, with a particular focus on all aspects relating to radiotherapy, including the current evidence base, associations with chemotherapy and surgery, treatment volumes and planning, technological advances, and reradiation.
PubMed: 34513595
DOI: 10.5306/wjco.v12.i8.581