Objectives: It is widely accepted that extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) should be performed as part of a multi-modality therapy program. Chemotherapy has conventionally been given postoperatively but there is recent interest in preoperative chemotherapy. The geographical variability in our oncological practice has allowed us to compare the impact of preoperative versus postoperative systemic chemotherapy in this setting.
Methods: From a prospective database 118 consecutive patients who underwent EPP for resectable epithelioid or biphasic MPM were analyzed, 94 patients (86.1% male, median age 57.0 years) were included. 29 patients received preoperative chemotherapy and 65 were treated in an intention-to-treat basis with postoperative chemotherapy. The choice of regime was dependent on referring oncologist preference. Immediate and late outcomes were compared using the Mann-Whitney U test, Kaplan-Meier method and the Log-rank test.
Results: The two groups has similar demographics and surgical stage. 2 of 29 (7%) patients progressed on preoperative chemotherapy and became inoperable; 30 of 65 (46%) patients did not proceed to postoperative chemotherapy due to poor health. Both groups received similar cisplatin-based doublet chemotherapy regimes. No significant differences in perioperative recovery could be seen with exception of a significant better 90-day mortality in de postoperative chemotherapy group(20.7% vs 6.2%, p<0.05). Overall 1-year, 2-year and median survival were 62%, 31% and 17.9 months respectively in the preoperative group and 71%, 40% and 19 months respectively in the postoperative group (p<0.05).
Conclusions: Whilst the timing of chemotherapy does not compromise perioperative recovery there is no survival evidence to support routine use of pre-EPP chemotherapy.
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