Extended Pleurectomy/Decortication in Malignant Pleural Mesothelioma: preceding or following chemotherapy? Perioperative data and short-term outcomes

AIMS OF THE STUDY: Malignant Pleural Mesothelioma (MPM) is an aggressive asbestos-related malignancy with very poor prognosis, arising from the mesothelium of the pleural cavity. Despite of the fact MPM is considered a rare disease, its incidence varies greatly among different areas in the world, mainly because its pathogenesis is linked almost univocally to asbestos fibers exposure. Unfortunately, the province of Pavia has been marked by the highest Lombardy incidence of MPM due to the presence in Broni until 2000 of “Fibronit” - the second largest asbestos cement factory in Italy.Nowadays, MPM management consists in a multidisciplinary approach with chemotherapy, surgery, and radiotherapy in selected cases. The treatment goal with surgery is to achieve macroscopic complete resection (MCR), defined as the removal of all grossly visible and palpable tumor in the affected hemithorax. In our center, the operation of choice for curative intent is extended pleurectomy/decortication (EPD), which is defined as the parietal and visceral pleurae exeresis, including the diaphragm and /or the pericardium. Although the trimodal treatment scheme for MPM has been uniformly accepted, the timing of the different treatment modality has not been standardized yet. In particular, the multidisciplinary group of intrathoracic neoplasia in our center discusses the treatment strategy case by case, opting either for neoadjuvant chemotherapy followed by EPD (NCT/EPD) or oppositely for EPD followed by adjuvant chemotherapy (EPD/ACT) with or without radiotherapy. The aim of this study is to analyze retrospectively and compare the perioperative data and short-term outcomes of our patients undergoing NCT/EPD vs EPD/ACT. We evaluated the data concerning postoperative hospitalization length and course, postoperative complications, need of blood transfusion, 1st CT scan follow-up for disease progression and measurement of the surgical specimen thickness of the affected pleurae. The results will be useful for future case-by-case discussions to properly identify and refer to the appropriate surgery timing for patients affected by MPM. Our preliminary results highlight how the EPD/ACT sequence in our center appears to show an increased feasibility and safety of surgery preceding chemotherapy, accompanied by better short-term outcomes.