Extrapleural Pneumonectomy After Induction Chemotherapy: Perioperative Outcome in 251 Mesothelioma Patients From Three High-Volume Institutions

Annals of Thoracic Surgery. 2014 August 7. [Epub ahead of print] [Link]

Lauk O, Hoda MA, de Perrot M, Friess M, Klikovits T, Klepetko W, Keshavjee S, Weder W, Opitz I.



Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.


251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.


The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p = 0.001 and p < 0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p = 0.001 and p < 0.0005; and p = 0.002 and p < 0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p = 0.01) and after longer operations (p < 0.0005). Empyema (p < 0.0005) and acute respiratory distress syndrome (p = 0.02) were associated with longer duration of operation.


EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.