Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma

European Journal of Cardio-Thoracic Surgery. 2006 Feb 20; [Epub ahead of print] Received 23 September 2005;  revised 26 December 2005;  accepted 10 January 2006.  Available online 21 February 2006. [Link]

Isabelle Opitza, Peter Kestenholza, Didier Lardinoisa, Michael Müllera, Valentin Roussonc, Didier Schneitera, Rolf Stahelb and Walter Wedera,

aDivision of Thoracic Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
bDivision of Oncology, University Hospital Zurich, Switzerland
cInstitute for Biostatistics and Preventive Medicine, Switzerland


Objective: To investigate the incidence and management of postoperative complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.

Methods: Patients with histologically proven mesothelioma of clinical stages T1–3, N0–2, M0 and considered to be completely resectable received neoadjuvant chemotherapy (cisplatin + gemcitabine or cisplatin + pemetrexed) followed by extrapleural pneumonectomy and postoperative radiotherapy. The incidence and management of postoperative complications in general and of bronchopleural fistula and postpneumonectomy-empyema in particular were analyzed. Univariate analysis was performed to identify prognostic factors [sex, age, side of operation, weight loss, smoking, chemotherapy, EORTC-score (European Organization for Research and Treatment of Cancer-classification) and duration of operation].

Results: Between 1st May 1999 and 15th August 2005, 63 patients underwent complete extrapleural pneumonectomy after neoadjuvant chemotherapy. Postoperative complications were observed in 39 cases (62%) and 2 patients died within 30 days (3.2%). Postpneumonectomy-empyema occurred in 15.8% of the patients (n = 10), six with a bronchopleural fistula on the right side. All empyemas were treated successfully. Five patients developed chylothorax (7.9%) and four patients had complications due to a patch failure: cardiac herniation (n = 2), restriction of cardiac output (n = 1) or gastric herniation (n = 1). Patients with higher EORTC-score presented significantly more postoperative complications (p = 0.03). A longer duration of surgery tended to be associated with a higher incidence of postoperative complications, especially of empyemas.

Conclusions: Extrapleural pneumonectomy after neoadjuvant chemotherapy can be performed with mortality rates comparable to standard pneumonectomies. Complications are frequent but can be successfully managed; the EORTC-score seems to be a predictor for postoperative complications.

Keywords: Extrapleural pneumonectomy; Complications; Neoadjuvant chemotherapy; Malignant pleural mesothelioma; EORTC-score