122: Extrapleural Pneumonectomy for Pleural Malignancies

Introduction

Diffuse malignant pleural mesothelioma is a rare aggressive cancer associated with asbestos exposure. Approximately 2000 to 3000 cases occur annually. The natural history is defined by a median survival of 4 to 12 months with no treatment. Difficulties in diagnosis, staging, and treatment have made mesothelioma a challenging entity for most clinicians.

In the 1940s, Sarot¹ first described the technique of extrapleural pneumonectomy (EPP) for tuberculous empyema. In the 1980s, the operation was applied to diffuse malignant pleural mesothelioma and later to other malignancies, including locally advanced lung cancer and thymoma. In 1976, Butchart and associates reported a prohibitive operative mortality of 31%, but other series have reported a mortality range of 6% to 13%.² In the 1990s, significant improvements in mortality rates were achieved. In 1999, our institution reported the lowest published operative mortality of 3.8%.³ A retrospective study of our results from the Brigham and Women's Hospital/Dana Farber Cancer Institute was reported, representing the largest single-institution review of 328 patients with mesothelioma who underwent EPP between 1980 and 2000. With further experience, our operative mortality declined to 3.4%.⁴

Patient Selection and Preoperative Assessment

The significant improvement in perioperative mortality has been attributed to continuous refinements in technique and aggressive prevention and treatment of complications.^2,4 However, defined criteria for patient selection and comprehensive preoperative assessment also have contributed to the improvement in surgical results.

To be considered a candidate for EPP, a patient must meet several preoperative criteria (Table 122-1). The patient must have a Karnofsky performance status of greater than 70, normal liver and renal function tests, a room air arterial Pco₂ of less than 45 mm Hg, and a room air arterial Po₂ of greater than 65 mm Hg. While there is no strict age limit, we are hesitant to perform EPP in patients older than 70 years of age. A pulmonary function test that reveals a forced expiratory volume in 1 second (FEV₁) greater than 2 L is considered adequate for pneumonectomy. Quantitative ventilation/perfusion scan is indicated if the FEV₁ is less than 2 L. The combination of ventilation/perfusion scan and preoperative FEV₁ is used to predict postoperative lung function. Patients with a predicted postoperative FEV₁ of greater than 0.8 are acceptable candidates for EPP. Patients with a predicted postoperative FEV₁ of less than 0.8 L are considered for pleurectomy and decortication (see Chapter 121).